Provider Demographics
NPI:1467612465
Name:HILLIS, JORDAN TYLER (DDS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:TYLER
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 1:96 WEBSTER DR
Mailing Address - Street 2:
Mailing Address - City:ASHDOWN
Mailing Address - State:AR
Mailing Address - Zip Code:71822-9103
Mailing Address - Country:US
Mailing Address - Phone:870-898-8888
Mailing Address - Fax:870-898-4650
Practice Address - Street 1:96 WEBSTER DR
Practice Address - Street 2:
Practice Address - City:ASHDOWN
Practice Address - State:AR
Practice Address - Zip Code:71822-9103
Practice Address - Country:US
Practice Address - Phone:870-898-8888
Practice Address - Fax:870-898-4650
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3665122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist