Provider Demographics
NPI:1043784606
Name:EZELL, ELIZABETH JENE (RDH)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JENE
Last Name:EZELL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.B. 599
Mailing Address - Street 2:604 N. THOMAS ST.
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970
Mailing Address - Country:US
Mailing Address - Phone:434-447-4464
Mailing Address - Fax:434-447-2249
Practice Address - Street 1:604 N. THOMAS ST.
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970
Practice Address - Country:US
Practice Address - Phone:434-447-4464
Practice Address - Fax:434-447-2249
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402207520124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist