Provider Demographics
NPI:1639278039
Name:ELLIS, KENNETH CLAY JR (DMD, LLC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CLAY
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:DMD, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 S 5TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-4253
Mailing Address - Country:US
Mailing Address - Phone:256-543-1285
Mailing Address - Fax:256-543-1719
Practice Address - Street 1:311 S 5TH ST STE A
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-4253
Practice Address - Country:US
Practice Address - Phone:256-543-1285
Practice Address - Fax:256-543-1719
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL38421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL008303580Medicaid
ALT95656Medicare UPIN