Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 34172 | TX |
NPI | 1003309592 |
---|---|
Provider Name | Courtney Cunningham Ellis |
First Address | Dallas, TX 75202-1260 |
Second Address | Dallas, TX 75202-1260 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2018 |
Last Update Date | 22/08/2019 |