Provider Demographics
NPI:1235347436
Name:ELLIS, GEORGE E (DMD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:E
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 TRADE CENTER LN
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-2319
Mailing Address - Country:US
Mailing Address - Phone:601-894-4016
Mailing Address - Fax:601-894-1751
Practice Address - Street 1:108 TRADE CENTER LN
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-2319
Practice Address - Country:US
Practice Address - Phone:601-894-4016
Practice Address - Fax:601-894-1751
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2336871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060353Medicaid