Provider Demographics
NPI:1164427688
Name:GILLIS, EDWARD ROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ROY
Last Name:GILLIS
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 1:8600 SNOWDEN RIVER PKWY
Mailing Address - Street 2:STE 106
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-1982
Mailing Address - Country:US
Mailing Address - Phone:410-730-2020
Mailing Address - Fax:
Practice Address - Street 1:10203 TANAGER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3904
Practice Address - Country:US
Practice Address - Phone:410-730-3800
Practice Address - Fax:410-730-9665
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD43171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice