Provider Demographics
NPI:1972851814
Name:DENTAL GROUP OF ELLISVILLE, PLLC
Entity Type:Organization
Organization Name:DENTAL GROUP OF ELLISVILLE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LAKE
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-271-8710
Mailing Address - Street 1:97 HAL CROCKER ROAD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437
Mailing Address - Country:US
Mailing Address - Phone:601-477-3779
Mailing Address - Fax:601-477-3770
Practice Address - Street 1:97 HAL CROCKER ROAD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437
Practice Address - Country:US
Practice Address - Phone:601-477-3779
Practice Address - Fax:601-477-3770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2940-961223G0001X
MS3638-121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660377Medicaid