Provider Demographics
NPI:1033269840
Name:ELLISVILLE FAMILY DENTAL CENTER PA
Entity Type:Organization
Organization Name:ELLISVILLE FAMILY DENTAL CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SURBER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-477-3771
Mailing Address - Street 1:401 HIGHWAY 11 S
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-3103
Mailing Address - Country:US
Mailing Address - Phone:601-477-3771
Mailing Address - Fax:
Practice Address - Street 1:401 HIGHWAY 11 S
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-3103
Practice Address - Country:US
Practice Address - Phone:601-477-3771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2366-871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS=========OtherTAX ID