Provider Demographics
NPI:1770787467
Name:JONES, ELLY JO (DMD)
Entity type:Individual
Prefix:DR
First Name:ELLY
Middle Name:JO
Last Name:JONES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MC KEE
Mailing Address - State:KY
Mailing Address - Zip Code:40447-7089
Mailing Address - Country:US
Mailing Address - Phone:606-287-7104
Mailing Address - Fax:606-287-4409
Practice Address - Street 1:1010 MAIN ST S
Practice Address - Street 2:
Practice Address - City:MC KEE
Practice Address - State:KY
Practice Address - Zip Code:40447-7089
Practice Address - Country:US
Practice Address - Phone:606-287-7104
Practice Address - Fax:606-287-4409
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8508122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100013390Medicaid