Provider Demographics
NPI:1619945433
Name:DILLARD, FREDERICK M (DMD)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:M
Last Name:DILLARD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:F
Other - Middle Name:MATT
Other - Last Name:DILLARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2270 ASHLEY CROSSING DR
Mailing Address - Street 2:STE 175
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5732
Mailing Address - Country:US
Mailing Address - Phone:843-410-5766
Mailing Address - Fax:843-410-5767
Practice Address - Street 1:2270 ASHLEY CROSSING DR
Practice Address - Street 2:STE 175
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5732
Practice Address - Country:US
Practice Address - Phone:843-410-5766
Practice Address - Fax:843-410-5767
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3868Medicaid
SCAA19781983Medicare UPIN
SCZX3868Medicaid