MEDICARE: DR. RICHARD IVY EZELL 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	1929	AR

General Provider Information

NPI Number	:	1336156702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD IVY EZELL D.D.S.

Provider Business Mailing Address
First Line	:	2017 N GREEN ACRES RD
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-2619
Country	:	US
Telephone Number	:	479-521-6292
Fax Number	:	479-521-0655

Provider Business Practice Location Address
First Line	:	2017 N GREEN ACRES RD
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-2619
Country	:	US
Telephone Number	:	479-521-6292
Fax Number	:	479-521-0655

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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