Provider Demographics
NPI:1639112345
Name:ELLIS, SAMMY DALE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMMY
Middle Name:DALE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:SAMMY
Other - Middle Name:DALE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2221 KNOLLWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078
Mailing Address - Country:US
Mailing Address - Phone:770-972-7911
Mailing Address - Fax:770-978-3767
Practice Address - Street 1:2221 KNOLLWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078
Practice Address - Country:US
Practice Address - Phone:770-972-7911
Practice Address - Fax:770-978-3767
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0123201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA19NCCDSMedicare ID - Type Unspecified
U94807Medicare UPIN