Provider Demographics
NPI:1407056153
Name:GILLIAM, MAXWELL L (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:L
Last Name:GILLIAM
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 1:2 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7325
Mailing Address - Country:US
Mailing Address - Phone:910-577-5077
Mailing Address - Fax:910-577-1907
Practice Address - Street 1:2 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7325
Practice Address - Country:US
Practice Address - Phone:910-577-5077
Practice Address - Fax:910-577-1907
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC56881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC063744OtherUNITED CONCORDIA
NC8993182Medicaid
NC014CYOtherBCBS