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General NPI Number Information
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NPI Number | 1326059122
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Entity Type | Individual
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Provider Name | VIRGIL EDWARD ELLIS III D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/10/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 405 HOGAN LN SUITE 2
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City | CONWAY
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State | AR
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Zip | 72034-8201
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Country | US
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Telephone | 501-329-1994
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Fax | 501-329-1979
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Provider Business Mailing Address
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Address Line | PO BOX 10605
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City | CONWAY
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State | AR
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Zip | 72034-0010
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Country | US
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Telephone | 501-329-1994
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Fax | 501-329-1979
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 3221
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License Number State | AR
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