Healthcare Provider Details

I. General information

NPI: 1558795930
Provider Name (Legal Business Name): TERRY R. ELLIS, DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 AUGUSTA WEST PKWY
AUGUSTA GA
30909-1854
US

IV. Provider business mailing address

1244 AUGUSTA WEST PKWY
AUGUSTA GA
30909-1854
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 Number
License Number State

VIII. Authorized Official

Name: DR. TERRY R ELLIS
Title or Position: PRESIDENT
Credential: DMD
Phone: 706-855-7220