Basic Information
| Provider Information | |||||||||
| NPI: | 1215482757 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RONALD H. ELLINGSEN, DDS, MSD, PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9915 N DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992181303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094672606 | ||||||||
| FaxNumber: | 5094658272 | ||||||||
| Practice Location | |||||||||
| Address1: | 9915 N DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992181303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094672606 | ||||||||
| FaxNumber: | 5094658272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2016 | ||||||||
| LastUpdateDate: | 08/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | ELLINGSEN | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SEC/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 5094672606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | DE00006353 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
ID Information
| ID | Type | State | Issuer | Description | 5033576 | 05 | WA | MEDICAID |