Provider Demographics
NPI:1194900464
Name:SPENCER A. ELLIS
Entity type:Organization
Organization Name:SPENCER A. ELLIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-663-4444
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37756-0209
Mailing Address - Country:US
Mailing Address - Phone:423-663-4444
Mailing Address - Fax:423-663-4439
Practice Address - Street 1:170 SCOTT HIGH DR
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37756-4152
Practice Address - Country:US
Practice Address - Phone:423-663-4444
Practice Address - Fax:423-663-4439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS76461223G0001X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3139906OtherBLUE CROSS BLUE SHEILD