Provider Demographics
NPI:1396759189
Name:ELLIS, ROGER TERRY (DDS)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:TERRY
Last Name:ELLIS
Suffix:
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 1:1718 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4542
Mailing Address - Country:US
Mailing Address - Phone:931-552-4935
Mailing Address - Fax:931-552-0959
Practice Address - Street 1:1718 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4542
Practice Address - Country:US
Practice Address - Phone:931-552-4935
Practice Address - Fax:931-552-0959
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU71539Medicare UPIN
TN3226263Medicare ID - Type Unspecified