Provider Demographics
NPI:1881855534
Name:ELLETT, MITCHELL F JR (DMD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:F
Last Name:ELLETT
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 LILLIAN DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6902
Mailing Address - Country:US
Mailing Address - Phone:864-235-3949
Mailing Address - Fax:
Practice Address - Street 1:102 EDINBURGH CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2530
Practice Address - Country:US
Practice Address - Phone:864-235-3949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4479122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist