# SPENCER A. ELLIS

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Ellis Family Dentistry
- **Organization subpart:** No

## Provider details

- **NPI number:** 1194900464
- **Authorized official:** SPENCER A. ELLIS D.D.S. (OWNER)
- **Authorized official phone:** (423) 663-4444

## Contact information

- **Practice address:** 170 SCOTT HIGH DR, HUNTSVILLE, TN 37756-4152
- **Practice address phone:** (423) 663-4444
- **Practice address fax:** (423) 663-4439
- **Mailing address:** PO BOX 209, HUNTSVILLE, TN 37756-0209
- **Mailing address phone:** (423) 663-4444
- **Mailing address fax:** (423) 663-4439

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | DS7646 | TN | Yes |
| 332BC3200X | Customized Equipment (DME) | — | NULL | — |

## Other

- **Enumeration date:** 01/07/2008
- **Last updated:** 10/02/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 3139906 | BLUE CROSS BLUE SHEILD | TN |