Provider Demographics
NPI:1720153729
Name:EZELL, JERRY GUWAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:GUWAYNE
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 1:1403 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282-5513
Mailing Address - Country:US
Mailing Address - Phone:318-574-0765
Mailing Address - Fax:318-493-5085
Practice Address - Street 1:1403 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-5513
Practice Address - Country:US
Practice Address - Phone:318-574-0765
Practice Address - Fax:318-493-5085
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA44791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice