Provider Demographics
NPI:1356494462
Name:TILLERY, MICHAEL FREDRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:FREDRICK
Last Name:TILLERY
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 1:3410 N HIGH SCHOOL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-1742
Mailing Address - Country:US
Mailing Address - Phone:317-291-8957
Mailing Address - Fax:317-291-2115
Practice Address - Street 1:3410 N HIGH SCHOOL RD
Practice Address - Street 2:SUITE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-1742
Practice Address - Country:US
Practice Address - Phone:317-291-8957
Practice Address - Fax:317-291-2115
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007704A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist