Basic Information
| Provider Information | |||||||||
| NPI: | 1417041146 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLSWORTH COX PEDIATRIC DENTISTRY LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ANTHEM PEDIATRIC DENTISTRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2843 SAINT ROSE PKWY | ||||||||
| Address2: | #100 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890524813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025315437 | ||||||||
| FaxNumber: | 7026163565 | ||||||||
| Practice Location | |||||||||
| Address1: | 2843 SAINT ROSE PKWY | ||||||||
| Address2: | #100 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890524813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025315437 | ||||||||
| FaxNumber: | 7026163565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 11/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | MENDOZA | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7024595437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 3696 | NV | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | 4341 | NV | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 3696 | 01 | NV | STATE LICENSE NUMBER | OTHER | 4341 | 01 | NV | STATE LICENSE NUMBER | OTHER |