Basic Information
| Provider Information | |||||||||
| NPI: | 1699124123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLSWORTH | ||||||||
| FirstName: | TY | ||||||||
| MiddleName: | |||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3630 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860033630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285229879 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2650 E SHOW LOW LAKE RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285374300 | ||||||||
| FaxNumber: | 9285326901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D009461 | AZ | Y | Dental Providers | Dentist |
No ID Information.