The holder whose full name is Ellsworth, Richard Dale,come from LAFAYETTE IN,hold the CSR-Dentist license(NO.12007107B) which status is Active.
| Name | Ellsworth, Richard Dale |
|---|---|
| License Number | 12007107B |
| License Type | CSR-Dentist |
| License Status | Active |
| City | LAFAYETTE |
| State | IN |