Provider Demographics
NPI:1376656041
Name:TILLERY DENTAL CLINICS, P.A.
Entity Type:Organization
Organization Name:TILLERY DENTAL CLINICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:TILLERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-428-6093
Mailing Address - Street 1:1508 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-2668
Mailing Address - Country:US
Mailing Address - Phone:601-428-6093
Mailing Address - Fax:601-428-6096
Practice Address - Street 1:1508 W 10TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2668
Practice Address - Country:US
Practice Address - Phone:601-428-6093
Practice Address - Fax:601-428-6096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS1332681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty