Jeffrey Mark Ellis, D.D.S., M.S.,C.N.S

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

039551 Issued in NY

Practice address

3237 Route 112
BLDG 6
Medford, NY 11763-1424

Phone

(631) 698-6934

Fax

(631) 698-5361

NPI assigned

Mar 6, 2007

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in NY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Certified Nurse Specialist, Master of Science

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

{
    "created_epoch": "1173139200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1417087719",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3237 ROUTE 112",
            "address_2": "BLDG 6",
            "city": "MEDFORD",
            "state": "NY",
            "postal_code": "117631424",
            "telephone_number": "631-698-6934",
            "fax_number": "631-698-5361"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3237 ROUTE 112",
            "address_2": "BLDG 6",
            "city": "MEDFORD",
            "state": "NY",
            "postal_code": "117631424",
            "telephone_number": "631-698-6934",
            "fax_number": "631-698-5361"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLIS",
        "first_name": "JEFFREY",
        "middle_name": "MARK",
        "name_prefix": "Dr.",
        "credential": "D.D.S., M.S.,C.N.S",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-03-06",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NY",
            "license": "039551",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• General Practice Dentistry in Medford, NY
• Providers in Medford, NY by specialty
• General Practice Dentistry in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.