Provider Demographics
NPI:1275775199
Name:ELLISON, CHERI G (R D H)
Entity Type:Individual
Prefix:MRS
First Name:CHERI
Middle Name:G
Last Name:ELLISON
Suffix:
Gender:F
Credentials:R D H
Other - Prefix:MRS
Other - First Name:CHERYL
Other - Middle Name:G
Other - Last Name:ELLISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:R D H
Mailing Address - Street 1:7052 PATRICK RD
Mailing Address - Street 2:
Mailing Address - City:CITRONELLE
Mailing Address - State:AL
Mailing Address - Zip Code:36522
Mailing Address - Country:US
Mailing Address - Phone:251-610-2455
Mailing Address - Fax:
Practice Address - Street 1:7052 PATRICK RD
Practice Address - Street 2:
Practice Address - City:CITRONELLE
Practice Address - State:AL
Practice Address - Zip Code:36522-5145
Practice Address - Country:US
Practice Address - Phone:251-610-2455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5121124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALMAY2762OtherNPI