Provider Demographics
NPI:1609286061
Name:MICHAEL F. TILLERY DDS & ASSOCIATES PC
Entity Type:Organization
Organization Name:MICHAEL F. TILLERY DDS & ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:FREDRICK
Authorized Official - Last Name:TILLERY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-291-8957
Mailing Address - Street 1:3410 N HIGH SCHOOL RD STE B
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-0002
Mailing Address - Country:US
Mailing Address - Phone:317-291-8957
Mailing Address - Fax:317-291-2115
Practice Address - Street 1:3410 N HIGH SCHOOL RD STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-0002
Practice Address - Country:US
Practice Address - Phone:317-291-8957
Practice Address - Fax:317-291-2115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN77041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100062710AMedicaid