Ellis, Randall William
Ellis, Randall William is an individual health care provider with primary practice located at 2859 E Fountain Blvd , Colorado Springs CO 80910-2312. He recently has only one registered license in Dental Providers / General Practice, which is considered as his primary health care specialty. Ellis, Randall William can be contacted via phone (719) 442-0071.Contact Information
Primary practice address
2859 E Fountain Blvd
Colorado Springs CO 80910-2312
Phone: (719) 442-0071
Fax: (719) 473-5303
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Dental Providers / General Practice | 1223G0001X | DEN-8475 | Colorado |
| Dental Providers / General Practice | 1223G0001X | D4260 | Idaho |
| Dental Providers / General Practice | 1223G0001X | 4783 | Oklahoma |
Profile Details
| NPI number | 1427026095 |
|---|---|
| LBN Legal business name | Ellis, Randall William |
| Credentials | Doctor of Dental Surgery (DDS) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Mar 9th, 2006 |
| Last updated | Jun 1st, 2012 - about 13 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1427026095 | NPPES |
| New Mexico | MEDICAID | 41506367 | |
| New Mexico | MEDICAID | 200371660A | |
| New Mexico | MEDICAID | 04880323 |
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