Organization
DEW ANTI-AGING AND MED SPA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GILLIAN A ELLIS MD (OWNER/PROVIDER)
(407) 963-0125
Entity
Organization
Contact information
Practice address
7300 SANDLAKE COMMONS BLVD STE 315, ORLANDO, FL 32819-8011
(407) 963-0125
Mailing address
1624 KENNESAW DR, CLERMONT, FL 34711-6871
(407) 963-0125
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
—
—
261Q00000X
Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003163400
—
FL
Enumeration date
07/14/2020
Last updated
07/14/2020
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