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General NPI Number Information
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NPI Number | 1033269840
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Entity Type | Organization
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Legal Business Name | ELLISVILLE FAMILY DENTAL CENTER PA
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 08/31/2016
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Provider Practice Location Address
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Address Line | 401 HIGHWAY 11 S
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City | ELLISVILLE
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State | MS
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Zip | 39437-3103
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Country | US
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Telephone | 601-477-3771
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Fax |
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Provider Business Mailing Address
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Address Line | 401 HIGHWAY 11 S
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City | ELLISVILLE
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State | MS
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Zip | 39437-3103
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Country | US
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Telephone | 601-477-3771
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | STEPHEN L SURBER
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Credential | DMD
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Telephone | 601-477-3771
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2366-87
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License Number State | MS
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