Provider Demographics
NPI:1760219745
Name:ELLIS, NATHANIAL PRESTON (DMD)
Entity type:Individual
Prefix:DR
First Name:NATHANIAL
Middle Name:PRESTON
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16811 DESTREHAN DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-6996
Mailing Address - Country:US
Mailing Address - Phone:503-209-2870
Mailing Address - Fax:
Practice Address - Street 1:13236 NORTHWEST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77040-6003
Practice Address - Country:US
Practice Address - Phone:281-447-2186
Practice Address - Fax:281-447-0892
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX409381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice