Individual
DR. CHARLES LEE ELLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS, MD
Contact information
Practice address
2353 S RIDGE ROAD, GREEN BAY, WI 54304-5069
(920) 499-0471
(920) 499-8312
Mailing address
2353 S RIDGE ROAD, GREEN BAY, WI 54304-5069
(920) 499-0471
(920) 499-8312
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
8919
NC
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
019022235
IL
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
0401411258
VA
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
8919
NC
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
0101058265
VA
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
8919
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5914023
—
NC
Enumeration date
10/18/2006
Last updated
08/20/2025
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