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General NPI Number Information
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NPI Number | 1407414956
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Entity Type | Individual
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Provider Name | CHERRYL SUE ELLISON DDS
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Gender | Female
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Dates
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Enumeration Date | 05/30/2019
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Last Update Date | 01/14/2020
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Provider Practice Location Address
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Address Line | 105 COMMUNITY DR STE A
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City | SEYMOUR
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State | IN
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Zip | 47274-1955
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Country | US
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Telephone | 812-272-4602
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Fax |
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Provider Business Mailing Address
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Address Line | 3312 E ROY SCHMALZ CT
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City | BLOOMINGTON
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State | IN
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Zip | 47401-4445
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Country | US
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Telephone |
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 12013148A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 104713
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License Number State | CA
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