Provider Demographics
NPI:1578698031
Name:GILLILAND, SCOTT RUSSELL (DDS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:RUSSELL
Last Name:GILLILAND
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 1:24 CABERFAE HWY LOT 8
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-1171
Mailing Address - Country:US
Mailing Address - Phone:248-505-9132
Mailing Address - Fax:231-398-9304
Practice Address - Street 1:220 W GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1631
Practice Address - Country:US
Practice Address - Phone:231-547-6523
Practice Address - Fax:231-547-6238
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017529122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4798960Medicaid