Provider Demographics
NPI:1174613426
Name:EZELL, ALAN L I (DMD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:L
Last Name:EZELL
Suffix:I
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:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MS
Mailing Address - Zip Code:39341
Mailing Address - Country:US
Mailing Address - Phone:228-474-1314
Mailing Address - Fax:228-474-1348
Practice Address - Street 1:59 FRONTAGE RD N
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341
Practice Address - Country:US
Practice Address - Phone:662-726-4344
Practice Address - Fax:228-474-1348
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS233787122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060342Medicaid