Provider Demographics
NPI:1063509222
Name:E A TILLMAN & ASSOCIATES INC
Entity Type:Organization
Organization Name:E A TILLMAN & ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:E
Authorized Official - Middle Name:A
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-682-2408
Mailing Address - Street 1:285 N FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2751
Mailing Address - Country:US
Mailing Address - Phone:850-682-2408
Mailing Address - Fax:850-682-8755
Practice Address - Street 1:285 N FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2751
Practice Address - Country:US
Practice Address - Phone:850-682-2408
Practice Address - Fax:850-682-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL93411223G0001X
FL39151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL977588OtherUNITED CONCORDIA