Provider Demographics
NPI:1609912781
Name:TILLNER, MELISA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELISA
Middle Name:LYNN
Last Name:TILLNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 W DIVERSEY PKWY
Mailing Address - Street 2:4W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6227
Mailing Address - Country:US
Mailing Address - Phone:630-779-0692
Mailing Address - Fax:
Practice Address - Street 1:4410 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4011
Practice Address - Country:US
Practice Address - Phone:773-254-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice