Jeremy W Ellis, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

99-373-9289922 Issued in UT

Practice address

965 S 100 W
#102
Logan, UT 84321-6062

Phone

(435) 752-9741

Fax

(435) 753-5169

NPI assigned

Oct 5, 2006

Last updated

Jul 8, 2007By the provider in NPPES

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 UT

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

State licenses

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

{
    "created_epoch": "1160006400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1568558468",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "965 S 100 W",
            "address_2": "#102",
            "city": "LOGAN",
            "state": "UT",
            "postal_code": "843216062",
            "telephone_number": "435-752-9741",
            "fax_number": "435-753-5169"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "965 S 100 W",
            "address_2": "#102",
            "city": "LOGAN",
            "state": "UT",
            "postal_code": "843216062",
            "telephone_number": "435-752-9741",
            "fax_number": "435-753-5169"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLIS",
        "first_name": "JEREMY",
        "middle_name": "W",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-10-05",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "UT",
            "license": "99-373-9289922",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kasey Egbert, DPT
• Elevated Perspective
• Elite Physical Therapy and Wellness
• Madison Jo Elliott
• Candis Ann Ellis, CLC, CLE, CCCB
• Kevin Mark Ellsworth, O.D.
• Anne W. Elsweiler
• Embracing Authenticity Inc (New Beginnings Therapy)
• Empower Therapy Services LLC
• Jenny Erazo, LCSW

• General Practice Dentistry in Logan, UT
• Providers in Logan, UT by specialty
• General Practice Dentistry in Utah

• 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.