Provider Demographics
NPI:1699903567
Name:DANIELLE S. EZELL, DMD, PA
Entity type:Organization
Organization Name:DANIELLE S. EZELL, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:SUZETTE
Authorized Official - Last Name:EZELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:803-684-6545
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-0395
Mailing Address - Country:US
Mailing Address - Phone:803-684-6545
Mailing Address - Fax:803-684-0239
Practice Address - Street 1:9 W MADISON ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-1143
Practice Address - Country:US
Practice Address - Phone:803-684-6545
Practice Address - Fax:803-684-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4367122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4367Medicaid