Provider Demographics
NPI:1538585161
Name:MARK A. ELLIS, DMD, PLLC
Entity type:Organization
Organization Name:MARK A. ELLIS, DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:423-805-7500
Mailing Address - Street 1:951 RIVERFRONT PKWY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-2185
Mailing Address - Country:US
Mailing Address - Phone:423-805-7500
Mailing Address - Fax:
Practice Address - Street 1:951 RIVERFRONT PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-2185
Practice Address - Country:US
Practice Address - Phone:423-805-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty