Provider Demographics
NPI:1619995743
Name:ELLIS, MICHAEL BARRY (DMD,PA)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BARRY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DMD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:601-629-4100
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:601-629-4100
Practice Address - Fax:601-629-4101
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2047831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice