Active NPI
Jerry Guwayne Ezell, DDS
- General Practice Dentistry
- Tallulah, LA
National Provider Identifier
1720153729
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 4479
- Practice address
- 1403 Johnson St
Tallulah, LA 71282-5513 - Phone
- (318) 574-0765
- Fax
- (318) 493-5085
- NPI assigned
- Nov 22, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 4479 | LA | Primary |
Addresses
Primary practice location
1403 Johnson St
Tallulah, LA 71282-5513
Mailing address
1403 Johnson St
Tallulah, LA 71282-5513
Phone (318) 574-0765
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in LA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20151203001355 | LA | Order and Referring Only - Dentist | 8123328762 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4479 | LA | MD | Speech-Language Pathologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Delhi Dental Clinic | General Practice | Past | Accepting new patients |
| Joseph W. Yerger | General Practice | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1164153600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1663718400000",
"number": "1720153729",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1403 JOHNSON ST",
"city": "TALLULAH",
"state": "LA",
"postal_code": "712825513",
"telephone_number": "318-574-0765",
"fax_number": "318-493-5085"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1403 JOHNSON ST",
"city": "TALLULAH",
"state": "LA",
"postal_code": "712825513",
"telephone_number": "318-574-0765",
"fax_number": "318-493-5085"
}
],
"practiceLocations": [],
"basic": {
"last_name": "EZELL",
"first_name": "JERRY",
"middle_name": "GUWAYNE",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-11-22",
"last_updated": "2022-09-21",
"certification_date": "2022-09-21",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "LA",
"license": "4479",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Tallulah, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.