Provider Demographics
NPI:1508428954
Name:DANIEL J. DECILLIS, DDS, LLC
Entity Type:Organization
Organization Name:DANIEL J. DECILLIS, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DECILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-557-6101
Mailing Address - Street 1:1144 IOWA ST STE A
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1144 IOWA ST STE A
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2385
Practice Address - Country:US
Practice Address - Phone:541-482-4995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-06
Last Update Date:2019-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental