Provider Demographics
NPI:1326545625
Name:DECILLIS, DANIEL JORDAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JORDAN
Last Name:DECILLIS
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 1:1144 IOWA ST STE A
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2385
Mailing Address - Country:US
Mailing Address - Phone:541-482-4995
Mailing Address - Fax:
Practice Address - Street 1:1144 IOWA ST STE A
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520
Practice Address - Country:US
Practice Address - Phone:541-482-4995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2019-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD110051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice