Provider Demographics
NPI:1699980953
Name:VELLIS, JAMES G (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:VELLIS
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 1:800 ROSE STREET, ROOM D-432
Mailing Address - Street 2:UNIVERSITY OF KENTUCKY COLLEGE OF DENTISTRY
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0297
Mailing Address - Country:US
Mailing Address - Phone:859-323-5391
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE STREET, ROOM D-432
Practice Address - Street 2:UNIVERSITY OF KENTUCKY COLLEGE OF DENTISTRY
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0297
Practice Address - Country:US
Practice Address - Phone:859-323-5391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2012-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16925122300000X
KY9150122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1699980953Medicaid