Provider Demographics
NPI:1720672132
Name:HARPER LAWSON, ELLYN MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:ELLYN
Middle Name:MARIE
Last Name:HARPER LAWSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ELLYN
Other - Middle Name:MARIE
Other - Last Name:HARPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:7212 GRAPE HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5927
Mailing Address - Country:US
Mailing Address - Phone:304-290-4332
Mailing Address - Fax:
Practice Address - Street 1:3615 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3611
Practice Address - Country:US
Practice Address - Phone:540-772-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV44831223G0001X
VA04014171551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice