MEDICARE: DR. ELLIS KNOX LIST D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5687	NC
2	1223G0001X	General Practice Dentistry	30-01-8657	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	27028-1	OTHER	NC	BLUE CROSS/BLUE SHIELD #

General Provider Information

NPI Number	:	1114921764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLIS KNOX LIST D.D.S.

Provider Business Mailing Address
First Line	:	1014 LAMOND AVE
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27701-2021
Country	:	US
Telephone Number	:	919-682-5327
Fax Number	:	919-688-4588

Provider Business Practice Location Address
First Line	:	1014 LAMOND AVE
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27701-2021
Country	:	US
Telephone Number	:	919-682-5327
Fax Number	:	919-688-4588

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	07/08/2007

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Directions to “ DR. ELLIS KNOX LIST D.D.S.” Practice Location

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