Provider Demographics
NPI:1164635959
Name:ELLIS, JAMES W JR (DR)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 POPLAR GROVE CONNECTOR
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5915
Mailing Address - Country:US
Mailing Address - Phone:828-264-4995
Mailing Address - Fax:828-264-4997
Practice Address - Street 1:126 POPLAR GROVE CONNECTOR
Practice Address - Street 2:126 POPLAR GROVE CONNECTOR
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5915
Practice Address - Country:US
Practice Address - Phone:828-264-4995
Practice Address - Fax:828-264-4997
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3875122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0709KOtherBLUE CROSS
NC3404303Medicaid
NC3404485Medicaid
NC0709BOtherBLUE CROSS
NC3404395Medicaid
NC0709WOtherBLUE CROSS
NC3404305Medicaid