Provider Demographics
NPI:1487916557
Name:ELLIS, NATHEN J (DDS)
Entity type:Individual
Prefix:
First Name:NATHEN
Middle Name:J
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7206 AUSTIN SMILES CT STE 103
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-0517
Mailing Address - Country:US
Mailing Address - Phone:704-908-6969
Mailing Address - Fax:
Practice Address - Street 1:7206 AUSTIN SMILES CT STE 103
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-0517
Practice Address - Country:US
Practice Address - Phone:704-908-6969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9294122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist