Ellis Village Dental Group, Prof. Corp.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

ELLIS VILLAGE DENTAL GROUP, PROF. CORP.

Doing business as

Ellis Village Dental Group

Practice address

2100 Ellis Town Dr Ste 105
Tracy, CA 95377-9033

Phone

(209) 395-2393

Fax

(209) 229-4303

NPI assigned

Aug 17, 2026

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Khaled Entabi, DDS

Title

Owner

Phone

(209) 395-2393

Specialties & licenses 1

Addresses

Other names 1

• Ellis Village Dental Group Doing business as

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1786924800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1786924800000",
    "number": "1245145051",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 660041",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752660041",
            "telephone_number": "714-845-8890",
            "fax_number": "303-952-0892"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2100 ELLIS TOWN DR STE 105",
            "city": "TRACY",
            "state": "CA",
            "postal_code": "953779033",
            "telephone_number": "209-395-2393",
            "fax_number": "209-229-4303"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ELLIS VILLAGE DENTAL GROUP, PROF. CORP.",
        "organizational_subpart": "NO",
        "enumeration_date": "2026-08-17",
        "last_updated": "2026-08-17",
        "certification_date": "2026-08-17",
        "status": "A",
        "authorized_official_last_name": "ENTABI",
        "authorized_official_first_name": "KHALED",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "209-395-2393",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ellis Village Dental Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 17, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.