| Doctor Name: | KERISA SUE ELLOWAY |
| NPI Number: | 1154452324 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | D.D.S. |
| License Number: | 47254 |
| Business Practice Address: | 1730 Main St Suite A Fortuna, CA - 955402451 |
| Business Phone Number: | 7077251303 |
| Business Fax Number: | 7077251358 |
| Mailing Address: | 1730 Main St Ste A, FORTUNA |
| State: | CA |
| Postal Code: | 955402451 |
| Phone Number: | 7077251303 |
| Fax Number: | 7077251358 |
| NPI Enumeration Date: | 03/08/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223P0221X |
| License Number: | 47254 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | Pediatric Dentistry |
| Taxonomy Definition: | An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. |