Provider Demographics
NPI:1811569692
Name:ELLZEY, ALEXANDRIA THOMPSON (DDS)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:THOMPSON
Last Name:ELLZEY
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 1:4183 OLD FOREST RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-3058
Mailing Address - Country:US
Mailing Address - Phone:901-652-4086
Mailing Address - Fax:
Practice Address - Street 1:3030 COVINGTON PIKE STE 150
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-5041
Practice Address - Country:US
Practice Address - Phone:901-310-1441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN116561223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice