Provider Demographics
NPI:1629064415
Name:ELLIS, ANGELA GAIL (DDS, PA)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:GAIL
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8810 OCONEE CT
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-4841
Mailing Address - Country:US
Mailing Address - Phone:919-960-2969
Mailing Address - Fax:919-960-0551
Practice Address - Street 1:120 CONNER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-7092
Practice Address - Country:US
Practice Address - Phone:919-960-0155
Practice Address - Fax:919-960-0551
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC70611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901565Medicaid