Provider Demographics
NPI:1154635159
Name:ELLZEY-NICHOLS, MARGARET (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARGARET
Middle Name:
Last Name:ELLZEY-NICHOLS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 KENZIE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-4519
Mailing Address - Country:US
Mailing Address - Phone:601-270-7903
Mailing Address - Fax:601-883-2366
Practice Address - Street 1:1212 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-3137
Practice Address - Country:US
Practice Address - Phone:601-636-5321
Practice Address - Fax:601-636-5321
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3559-101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice