Provider Demographics
NPI:1609907096
Name:LILLEY, JOHN THOMAS JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:LILLEY
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1230 HAWORTH ST
Mailing Address - Street 2:PO BOX 9568
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2508
Mailing Address - Country:US
Mailing Address - Phone:215-535-2601
Mailing Address - Fax:215-289-7882
Practice Address - Street 1:1230 HAWORTH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2508
Practice Address - Country:US
Practice Address - Phone:215-535-2601
Practice Address - Fax:215-289-7882
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017800L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice