MEDICARE: DR. ELLIS BASIL MEMOS DDS

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	9757	MO

General Provider Information

NPI Number	:	1245340025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLIS BASIL MEMOS DDS

Provider Business Mailing Address
First Line	:	5108 HAMPTON AVE
Second Line	:
City	:	ST LOUIS
State	:	MO
Zip	:	63109-3113
Country	:	US
Telephone Number	:	314-832-4816
Fax Number	:	314-832-4811

Provider Business Practice Location Address
First Line	:	5108 HAMPTON AVE
Second Line	:
City	:	ST LOUIS
State	:	MO
Zip	:	63109-3113
Country	:	US
Telephone Number	:	314-832-4816
Fax Number	:	314-832-4811

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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