Provider Demographics
NPI:1992313951
Name:ELLZEY, BURKE LEE JR (DMD)
Entity type:Individual
Prefix:DR
First Name:BURKE
Middle Name:LEE
Last Name:ELLZEY
Suffix:JR
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 1:79 QUAIL HOLLOW DRIVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8972
Mailing Address - Country:US
Mailing Address - Phone:601-606-4241
Mailing Address - Fax:
Practice Address - Street 1:949 BROADWAY DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7534
Practice Address - Country:US
Practice Address - Phone:601-271-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4136-20122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist