Provider Demographics
NPI:1427131572
Name:ELLIS, CHARLES H (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:H
Last Name:ELLIS
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 1:6930 CAHABA VALLEY RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-2672
Mailing Address - Country:US
Mailing Address - Phone:205-991-7840
Mailing Address - Fax:205-991-9617
Practice Address - Street 1:6930 CAHABA VALLEY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-2672
Practice Address - Country:US
Practice Address - Phone:205-991-7840
Practice Address - Fax:205-991-9617
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3380CS1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice