Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 3691 | SC |
NPI | 1023079654 |
---|---|
Provider Name | Dr. Robert H. Ellis III |
First Address | Columbia, SC 29223-6367 |
Second Address | Columbia, SC 29223-6367 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
ZA9724 | (05) | SC |
ZX3691 | (05) | SC |