Provider Demographics
NPI:1477237337
Name:THAXTON, ELLA (RDH, CTTS)
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:
Last Name:THAXTON
Suffix:
Gender:F
Credentials:RDH, CTTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:MILLWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25262-0103
Mailing Address - Country:US
Mailing Address - Phone:304-539-1572
Mailing Address - Fax:
Practice Address - Street 1:1448 10TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3581
Practice Address - Country:US
Practice Address - Phone:304-529-0753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1572124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist