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General NPI Number Information
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NPI Number | 1114619657
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Entity Type | Organization
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Legal Business Name | RANDALL A. ELLIS, DDS, PLLC
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Dates
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Enumeration Date | 05/23/2023
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Last Update Date | 05/23/2023
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Provider Practice Location Address
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Address Line | 4617 SUMMERHILL RD STE 3
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City | TEXARKANA
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State | TX
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Zip | 75503-2783
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Country | US
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Telephone | 903-838-5506
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Fax |
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Provider Business Mailing Address
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Address Line | 4617 SUMMERHILL RD STE 3
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City | TEXARKANA
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State | TX
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Zip | 75503-2783
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Country | US
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Telephone | 39-838-5506
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | RANDALL ALLEN ELLIS
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Credential | DDS
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Telephone | 903-838-5506
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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 |
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License Number State |
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