Healthcare Provider Details

I. General information

NPI: 1275775199
Provider Name (Legal Business Name): CHERI G ELLISON R. D. H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHERYL G ELLISON R. D. H.

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7052 PATRICK RD
CITRONELLE AL
36522-5145
US

IV. Provider business mailing address

7052 PATRICK RD
CITRONELLE AL
36522
US

V. Phone/Fax

Practice location:
  • Phone: 251-610-2455
  • Fax:
Mailing address:
  • Phone: 251-610-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5121
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: