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General NPI Number Information
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NPI Number | 1487837423
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Entity Type | Organization
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Legal Business Name | SNELLVILLE ORAL SURGERY LLC
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Dates
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Enumeration Date | 12/13/2007
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Last Update Date | 02/21/2013
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Provider Practice Location Address
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Address Line | 2221 KNOLLWOOD DRIVE
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City | SNELLVILLE
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State | GA
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Zip | 30078
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Country | US
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Telephone | 770-972-7911
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Fax | 770-978-3767
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Provider Business Mailing Address
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Address Line | 2221 KNOLLWOOD DRIVE
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City | SNELLVILLE
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State | GA
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Zip | 30078
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Country | US
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Telephone | 770-972-7911
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Fax | 770-978-3767
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Authorized Official
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Title or Position | OWNER
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Name | DR. DALE ELLIS
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Credential | DMD
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Telephone | 770-972-7911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 07968
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DN012320
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License Number State | GA
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