Provider Demographics
NPI:1689743981
Name:GILLIS, MALCOLM EDWARD JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:EDWARD
Last Name:GILLIS
Suffix:JR
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 1:1201 HATCHER LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-3531
Mailing Address - Country:US
Mailing Address - Phone:931-381-9044
Mailing Address - Fax:931-540-0336
Practice Address - Street 1:1201 HATCHER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3531
Practice Address - Country:US
Practice Address - Phone:931-381-9044
Practice Address - Fax:931-540-0336
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS25851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice