Provider Demographics
NPI:1265426894
Name:ELLIS, MARK ALAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:ELLIS
Suffix:
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 1:951 RIVERFRONT PKWY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-2185
Mailing Address - Country:US
Mailing Address - Phone:423-805-7500
Mailing Address - Fax:423-805-7501
Practice Address - Street 1:951 RIVERFRONT PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-2185
Practice Address - Country:US
Practice Address - Phone:423-805-7500
Practice Address - Fax:423-805-7501
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2996971223G0001X
TN9594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice