Provider Demographics
NPI:1033120001
Name:TILLERY, DOUGLAS W (DDS)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
Last Name:TILLERY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-2668
Mailing Address - Country:US
Mailing Address - Phone:601-428-6093
Mailing Address - Fax:601-428-6096
Practice Address - Street 1:1508 W 10TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2668
Practice Address - Country:US
Practice Address - Phone:601-428-6093
Practice Address - Fax:601-428-6096
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS133268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist