Provider Demographics
NPI:1447884861
Name:ELLENTHAL, ADAM TAKEO (DDS, MPH)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:TAKEO
Last Name:ELLENTHAL
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 HIGH HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-3601
Mailing Address - Country:US
Mailing Address - Phone:919-267-4211
Mailing Address - Fax:
Practice Address - Street 1:1705 HIGH HOUSE RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-3601
Practice Address - Country:US
Practice Address - Phone:919-267-4211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MAPENDING1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program