Individual
LARISA ELLIS
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
DDS
Contact information
Practice address
263 MAIN ST, OLD SAYBROOK, CT 06475-2326
(860) 388-4433
(860) 388-4434
Mailing address
635 MAIN ST, ATTN: CREDENTIALING DEPARTMENT, MIDDLETOWN, CT 06457-2718
(860) 347-6971
(860) 638-6601
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
009502
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004236354
—
CT
Enumeration date
01/25/2006
Last updated
07/08/2007
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