Provider Demographics
NPI:1124046974
Name:BERRY, ROBERT ELLIS SR (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ELLIS
Last Name:BERRY
Suffix:SR
Gender:M
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:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-0638
Mailing Address - Country:US
Mailing Address - Phone:706-595-5785
Mailing Address - Fax:706-595-5786
Practice Address - Street 1:1025C WEST HILL ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824
Practice Address - Country:US
Practice Address - Phone:706-595-5785
Practice Address - Fax:706-595-5786
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7988122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist