Provider Demographics
NPI:1568545119
Name:ELLIS, TERESA EILEEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:EILEEN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 WEST AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4066
Mailing Address - Country:US
Mailing Address - Phone:931-484-3007
Mailing Address - Fax:
Practice Address - Street 1:1720 WEST AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4066
Practice Address - Country:US
Practice Address - Phone:931-784-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS81481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440078Medicaid