Provider Demographics
NPI:1487887097
Name:ELLIS, ERIN LYNN (DENTAL ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:LYNN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DENTAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 DAVID CT
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-5615
Mailing Address - Country:US
Mailing Address - Phone:770-949-7793
Mailing Address - Fax:770-422-4015
Practice Address - Street 1:805 CANTON ROAD
Practice Address - Street 2:STE D
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-0000
Practice Address - Country:US
Practice Address - Phone:770-422-8264
Practice Address - Fax:770-422-4015
Is Sole Proprietor?:No
Enumeration Date:2009-08-29
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant