Provider Demographics
NPI:1013098698
Name:ELLIS, CHARLES LEE (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LEE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2353 S RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5069
Mailing Address - Country:US
Mailing Address - Phone:920-499-0471
Mailing Address - Fax:920-499-8312
Practice Address - Street 1:2353 S RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5069
Practice Address - Country:US
Practice Address - Phone:920-499-0471
Practice Address - Fax:920-499-8312
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8919122300000X, 204E00000X, 1223S0112X
VA04014112581223S0112X
IL0190222351223S0112X
VA0101058265204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5914023Medicaid