Healthcare Provider Details

I. General information

NPI: 1023079654
Provider Name (Legal Business Name): ROBERT H. ELLIS III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8905 TWO NOTCH RD
COLUMBIA SC
29223-6367
US

IV. Provider business mailing address

8905 TWO NOTCH RD
COLUMBIA SC
29223-6367
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-9593
  • Fax: 803-788-3123
Mailing address:
  • Phone: 803-788-9593
  • Fax: 803-788-3123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10406
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3691
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: