Basic Information
| Provider Information | |||||||||
| NPI: | 1427026095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 W 8TH ST | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195624447 | ||||||||
| FaxNumber: | 7195831801 | ||||||||
| Practice Location | |||||||||
| Address1: | 2859 E FOUNTAIN BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809102312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194420071 | ||||||||
| FaxNumber: | 7194735303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 06/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DEN-8475 | CO | Y | Dental Providers | Dentist | General Practice | 1223G0001X | D4260 | ID | N | Dental Providers | Dentist | General Practice | 1223G0001X | 4783 | OK | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 41506367 | 05 | NM | MEDICAID | 200371660A | 05 | KS | MEDICAID | 04880323 | 05 | CO | MEDICAID |