Provider Demographics
NPI:1255307831
Name:ELLIS, TERRY RANDAL (DMD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:RANDAL
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 1:1244 AUGUSTA WEST PARKWAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909
Mailing Address - Country:US
Mailing Address - Phone:706-855-7220
Mailing Address - Fax:706-855-7260
Practice Address - Street 1:1244 AUGUSTA WEST PARKWAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909
Practice Address - Country:US
Practice Address - Phone:706-855-7220
Practice Address - Fax:706-855-7260
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0113931223S0112X
MS2541901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
19NCRXXMedicare ID - Type Unspecified
U57152Medicare UPIN