MEDICARE: DR. MARK ALAN ELLIS D.M.D.

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	299697	MS
2	122300000X	Dentist	9594	TN

General Provider Information

NPI Number	:	1265426894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK ALAN ELLIS D.M.D.

Provider Business Mailing Address
First Line	:	951 RIVERFRONT PKWY
Second Line	:	SUITE 302
City	:	CHATTANOOGA
State	:	TN
Zip	:	37402-2185
Country	:	US
Telephone Number	:	423-805-7500
Fax Number	:	423-805-7501

Provider Business Practice Location Address
First Line	:	951 RIVERFRONT PKWY
Second Line	:	SUITE 302
City	:	CHATTANOOGA
State	:	TN
Zip	:	37402-2185
Country	:	US
Telephone Number	:	423-805-7500
Fax Number	:	423-805-7501

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

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	03/06/2014

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