Basic Information
| Provider Information | |||||||||
| NPI: | 1841392172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLSWORTH | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D.,M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 SWINGLINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025647869 | ||||||||
| FaxNumber: | 7026163565 | ||||||||
| Practice Location | |||||||||
| Address1: | 2843 ST. ROSE PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025315437 | ||||||||
| FaxNumber: | 7026163565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | S6-39 | NV | Y | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.