Provider Demographics
NPI:1548611098
Name:ELLIS, KAITLYN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KAITLYN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KAITLYN
Other - Middle Name:ELLIS
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1008 MISSION PARK DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3735
Mailing Address - Country:US
Mailing Address - Phone:601-627-4100
Mailing Address - Fax:601-629-4101
Practice Address - Street 1:1008 MISSION PARK DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3735
Practice Address - Country:US
Practice Address - Phone:601-627-4100
Practice Address - Fax:601-629-4101
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS387216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist