Provider Demographics
NPI:1326328527
Name:HILLIS, MATTHEW W (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:W
Last Name:HILLIS
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:LANDSTUHL DENTAL ACTIVITY
Mailing Address - Street 2:CMR 402
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:314-487-4130
Mailing Address - Fax:
Practice Address - Street 1:LANDSTUHL DENTAL ACTIVITY
Practice Address - Street 2:CMR 402
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:US
Practice Address - Phone:314-487-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9345122300000X
TNDS0000093451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice