Provider Demographics
NPI:1497462105
Name:ELLIS, OLIVIA MICHELLE (RDH)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MICHELLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 ALTRURIA RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-2540
Mailing Address - Country:US
Mailing Address - Phone:901-356-4307
Mailing Address - Fax:
Practice Address - Street 1:3400 ALTRURIA RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38135-2540
Practice Address - Country:US
Practice Address - Phone:901-356-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7900124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist