Provider Demographics
NPI:1114921764
Name:LIST, ELLIS KNOX (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:KNOX
Last Name:LIST
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 1:1014 LAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-2021
Mailing Address - Country:US
Mailing Address - Phone:919-682-5327
Mailing Address - Fax:919-688-4588
Practice Address - Street 1:1014 LAMOND AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-2021
Practice Address - Country:US
Practice Address - Phone:919-682-5327
Practice Address - Fax:919-688-4588
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC56871223G0001X
OH30-01-86571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC27028-1OtherBLUE CROSS/BLUE SHIELD #
NCU41482Medicare UPIN