Provider Demographics
NPI:1548319130
Name:ELLIS, RENALLA KAYE (DDS)
Entity type:Individual
Prefix:
First Name:RENALLA
Middle Name:KAYE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 E INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1839
Mailing Address - Country:US
Mailing Address - Phone:405-273-2002
Mailing Address - Fax:405-273-0087
Practice Address - Street 1:2510 E INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1839
Practice Address - Country:US
Practice Address - Phone:405-273-2002
Practice Address - Fax:405-273-0087
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice