Provider Demographics
NPI:1720165236
Name:ENNIS, JAMES WALTER II (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WALTER
Last Name:ENNIS
Suffix:II
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:PO BOX 2230
Mailing Address - Street 2:2043 TYNECASTLE HWY
Mailing Address - City:BANNER ELK
Mailing Address - State:NC
Mailing Address - Zip Code:28604-2230
Mailing Address - Country:US
Mailing Address - Phone:828-898-8343
Mailing Address - Fax:
Practice Address - Street 1:2043 TYNECASTLE HWY
Practice Address - Street 2:
Practice Address - City:BANNER ELK
Practice Address - State:NC
Practice Address - Zip Code:28604-9710
Practice Address - Country:US
Practice Address - Phone:828-898-8343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6136122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8992501Medicaid
NC92501OtherBLUE CROSS BLUE SHIELD