Provider Demographics
NPI:1306002860
Name:ELLIS, DUSTIN SMITH
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:SMITH
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WILSON PIKE CIR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5252
Mailing Address - Country:US
Mailing Address - Phone:615-376-0034
Mailing Address - Fax:615-376-3488
Practice Address - Street 1:500 WILSON PIKE CIR
Practice Address - Street 2:SUITE 320
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5252
Practice Address - Country:US
Practice Address - Phone:615-376-0034
Practice Address - Fax:615-376-3488
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator