Provider Demographics
NPI:1093843484
Name:ELLISON, STACY BRIAN (DMD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:BRIAN
Last Name:ELLISON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 S HURSTBOURNE PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-4112
Mailing Address - Country:US
Mailing Address - Phone:502-491-0330
Mailing Address - Fax:502-491-7431
Practice Address - Street 1:2831 S HURSTBOURNE PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-4112
Practice Address - Country:US
Practice Address - Phone:502-491-0330
Practice Address - Fax:502-491-7431
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY59891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice