Provider Demographics
NPI:1306965140
Name:ELLIS, WILLARD JACKSON JR (DDS)
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:JACKSON
Last Name:ELLIS
Suffix:JR
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 1:3136 SUNSET AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-3650
Mailing Address - Country:US
Mailing Address - Phone:252-443-9121
Mailing Address - Fax:252-443-9836
Practice Address - Street 1:3136 SUNSET AVENUE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3650
Practice Address - Country:US
Practice Address - Phone:252-443-9121
Practice Address - Fax:252-443-9836
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC46331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7992473Medicaid
AE8793336OtherDEA