MEDICARE: DR. SUSAN ELLISON 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	122300000X	Dentist	15975	TX

General Provider Information

NPI Number	:	1861642092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN ELLISON DDS

Provider Business Mailing Address
First Line	:	12850 JONES RD STE 103
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-4956
Country	:	US
Telephone Number	:	281-890-2828
Fax Number	:	281-897-9793

Provider Business Practice Location Address
First Line	:	12850 JONES RD STE 103
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-4956
Country	:	US
Telephone Number	:	281-890-2828
Fax Number	:	281-897-9793

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

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	09/24/2008

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Directions to “ DR. SUSAN ELLISON DDS” Practice Location

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