Provider Demographics
NPI:1275667115
Name:DILLARD, DENNIS WAYNE (CPED, CTO)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:WAYNE
Last Name:DILLARD
Suffix:
Gender:M
Credentials:CPED, CTO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10823 W SMITHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HANNA CITY
Mailing Address - State:IL
Mailing Address - Zip Code:61536-9711
Mailing Address - Country:US
Mailing Address - Phone:309-565-7133
Mailing Address - Fax:
Practice Address - Street 1:741 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2017
Practice Address - Country:US
Practice Address - Phone:309-676-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL212-000127225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCPED1563OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS, PROSTHETICS, AND PEDORTHICS, INC.
IL212-000127OtherSTATE LICENSED PEDORTHIST