Provider Demographics
NPI:1538263132
Name:CARTER, ELLEN PHYLLIS (DDS)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:PHYLLIS
Last Name:CARTER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5180 PARK AVE
Mailing Address - Street 2:STE #260
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119
Mailing Address - Country:US
Mailing Address - Phone:901-683-5827
Mailing Address - Fax:901-766-1640
Practice Address - Street 1:5180 PARK AVE
Practice Address - Street 2:STE #260
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119
Practice Address - Country:US
Practice Address - Phone:901-683-5827
Practice Address - Fax:901-766-1640
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS40821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3224928Medicaid
TNQ000894Medicaid