Provider Demographics
NPI:1962571687
Name:ELLIS, MONA TW (DMD)
Entity type:Individual
Prefix:DR
First Name:MONA
Middle Name:TW
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1289 BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-3401
Mailing Address - Country:US
Mailing Address - Phone:803-533-0626
Mailing Address - Fax:803-533-0627
Practice Address - Street 1:1289 BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-3401
Practice Address - Country:US
Practice Address - Phone:803-533-0626
Practice Address - Fax:803-533-0627
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZZ2103Medicaid