Willard Jackson Ellis Jr., DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

4633 Issued in NC

Practice address

3136 Sunset Avenue
Rocky Mount, NC 27804-3650

Phone

(252) 443-9121

Fax

(252) 443-9836

NPI assigned

Mar 29, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175126400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1678147200000",
    "number": "1306965140",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3136 SUNSET AVENUE",
            "city": "ROCKY MOUNT",
            "state": "NC",
            "postal_code": "278043650",
            "telephone_number": "252-443-9121",
            "fax_number": "252-443-9836"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3136 SUNSET AVENUE",
            "city": "ROCKY MOUNT",
            "state": "NC",
            "postal_code": "278043650",
            "telephone_number": "252-443-9121",
            "fax_number": "252-443-9836"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLIS",
        "first_name": "WILLARD",
        "middle_name": "JACKSON",
        "name_suffix": "Jr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-03-29",
        "last_updated": "2023-03-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NC",
            "license": "4633",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7992473",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Nelson Richard Ehly, P.A.
• Eidson Speech and Language Services
• Stacy Corey Eidson, M.S., CCC/SLP
• Elizabeth E Miller DDS Ms PA (Rocky Mount Pediatric Dentistry)
• Jonta Elliott
• Randa Ibrahim Elsayed, MASTER'S DEGREE
• Hesham F Elwan
• Embracing Change Center, Inc.
• Embracing Touch Home Care Agency
• Courage Osifo Emokpae, MD

• General Practice Dentistry in Rocky Mount, NC
• Providers in Rocky Mount, NC by specialty
• General Practice Dentistry in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.