Provider Demographics
NPI:1023139169
Name:EZELL, STEPHEN E (DDS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:E
Last Name:EZELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 SW 152ND ST
Mailing Address - Street 2:SUITE # 101
Mailing Address - City:VILLAGE OF PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1981
Mailing Address - Country:US
Mailing Address - Phone:305-232-8515
Mailing Address - Fax:305-232-2425
Practice Address - Street 1:9000 SW 152ND ST
Practice Address - Street 2:SUITE # 101
Practice Address - City:VILLAGE OF PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1981
Practice Address - Country:US
Practice Address - Phone:305-232-8515
Practice Address - Fax:305-232-2425
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00110671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice