Provider Demographics
NPI:1356318687
Name:ELLIS, DAVID LARRY (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LARRY
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 1:3314 OAKLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-4704
Mailing Address - Country:US
Mailing Address - Phone:804-458-6733
Mailing Address - Fax:804-541-0416
Practice Address - Street 1:3314 OAKLAWN BLVD
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-4704
Practice Address - Country:US
Practice Address - Phone:804-458-6733
Practice Address - Fax:804-541-0416
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010052451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5245OtherDENTAL LICENSE NUMBER
VA122419OtherUNITED CONCORDIA NUMBER
VA9179650Medicaid
VA186711OtherANTHEM NUMBER