Provider Demographics
NPI:1972736882
Name:ELLISON, JILLIAN E (DMD)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:E
Last Name:ELLISON
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 1:136 PARTIN DR N
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2054
Mailing Address - Country:US
Mailing Address - Phone:850-678-7114
Mailing Address - Fax:
Practice Address - Street 1:136 PARTIN DR N
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2054
Practice Address - Country:US
Practice Address - Phone:850-678-7114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16159122300000X
MA19226122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist