MEDICARE: MRS. ERIN LYNN ELLIS DENTAL ASSISTANT

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	126800000X	Dental Assistant

General Provider Information

NPI Number	:	1487887097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ERIN LYNN ELLIS DENTAL ASSISTANT

Provider Business Mailing Address
First Line	:	112 DAVID CT
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-5615
Country	:	US
Telephone Number	:	770-949-7793
Fax Number	:	770-422-4015

Provider Business Practice Location Address
First Line	:	805 CANTON ROAD
Second Line	:	STE D
City	:	MARIETTA
State	:	GA
Zip	:	30060-0000
Country	:	US
Telephone Number	:	770-422-8264
Fax Number	:	770-422-4015

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

Provider Enumeration Date	:	08/29/2009
Last Update Date	:	10/06/2010

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