Individual
RANDALL WILLIAM ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2859 E FOUNTAIN BLVD, COLORADO SPRINGS, CO 80910-2312
(719) 442-0071
(719) 473-5303
Mailing address
201 W 8TH ST, SUITE 810, PUEBLO, CO 81003-3038
(719) 562-4447
(719) 583-1801
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
4783
OK
1223G0001X
General Practice Dentistry
D4260
ID
1223G0001X
General Practice Dentistry
Primary
DEN-8475
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04880323
—
CO
05
—
200371660A
—
KS
05
—
41506367
—
NM
Enumeration date
03/09/2006
Last updated
06/01/2012
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