Provider Demographics
NPI:1083749055
Name:EZELL, PHILIP WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:WAYNE
Last Name:EZELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-2309
Mailing Address - Country:US
Mailing Address - Phone:615-851-6800
Mailing Address - Fax:615-851-0392
Practice Address - Street 1:911 MEADOWLARK LN
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-2309
Practice Address - Country:US
Practice Address - Phone:615-851-6800
Practice Address - Fax:615-851-0392
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS85881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice