Healthcare Provider Details

I. General information

NPI: 1255307831
Provider Name (Legal Business Name): TERRY RANDAL ELLIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 AUGUSTA WEST PARKWAY
AUGUSTA GA
30909
US

IV. Provider business mailing address

1244 AUGUSTA WEST PARKWAY
AUGUSTA GA
30909
US

V. Phone/Fax

Practice location:
  • Phone: 706-855-7220
  • Fax: 706-855-7260
Mailing address:
  • Phone: 706-855-7220
  • Fax: 706-855-7260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN011393
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number254190
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: