Active NPI
Gary Lynn Ellis, DDS
- Oral and Maxillofacial Pathology Dentistry
- Salt Lake City, UT
National Provider Identifier
1700840717
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Oral and Maxillofacial Pathology Dentistry
- License
- 5129775-9921
- Practice address
- 500 Chipeta Way
Salt Lake City, UT 84108-1221 - Phone
- (801) 583-2787
- Fax
- (801) 584-5255
- NPI assigned
- Apr 14, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Oral and Maxillofacial Pathology Dentistry | 1223P0106X | 5129775-9921 | UT | Primary |
Addresses
Primary practice location
500 Chipeta Way
Salt Lake City, UT 84108-1221
Mailing address
500 Chipeta Way
Salt Lake City, UT 84108-1221
Phone (801) 583-2787
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 5129775-9921 | Other | UT | DENTAL LICENSE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5129775-9921 | UT | MD | Oral and Maxillofacial Pathology Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1144972800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1783900800000",
"number": "1700840717",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "500 CHIPETA WAY",
"city": "SALT LAKE CITY",
"state": "UT",
"postal_code": "841081221",
"telephone_number": "801-583-2787",
"fax_number": "801-584-5255"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "500 CHIPETA WAY",
"city": "SALT LAKE CITY",
"state": "UT",
"postal_code": "841081221",
"telephone_number": "801-583-2787",
"fax_number": "801-584-5255"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLIS",
"first_name": "GARY",
"middle_name": "LYNN",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-04-14",
"last_updated": "2026-07-13",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0106X",
"taxonomy_group": "",
"desc": "Dentist, Oral and Maxillofacial Pathology",
"state": "UT",
"license": "5129775-9921",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DENTAL LICENSE",
"identifier": "5129775-9921",
"state": "UT"
}
],
"endpoints": [],
"other_names": []
}Other providers in Salt Lake City, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 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.