MEDICARE: ROGER TERRY ELLIS 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	4003	TN

General Provider Information

NPI Number	:	1396759189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER TERRY ELLIS D.D.S.

Provider Business Mailing Address
First Line	:	1718 MEMORIAL DR
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37043-4542
Country	:	US
Telephone Number	:	931-552-4935
Fax Number	:	931-552-0959

Provider Business Practice Location Address
First Line	:	1718 MEMORIAL DR
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37043-4542
Country	:	US
Telephone Number	:	931-552-4935
Fax Number	:	931-552-0959

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

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	07/08/2007

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