Provider Demographics
NPI:1497816847
Name:LILLENBERG, JAMES E (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:E
Last Name:LILLENBERG
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 1:11428 TESSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6925
Mailing Address - Country:US
Mailing Address - Phone:314-846-6029
Mailing Address - Fax:314-824-0259
Practice Address - Street 1:11428 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6925
Practice Address - Country:US
Practice Address - Phone:314-846-6029
Practice Address - Fax:314-824-0259
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0129591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice