Provider Demographics
NPI:1710046552
Name:GILLIAM, GEORGE DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:DAVID
Last Name:GILLIAM
Suffix:
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 1:637 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4223
Mailing Address - Country:US
Mailing Address - Phone:276-783-5124
Mailing Address - Fax:276-783-2170
Practice Address - Street 1:637 PARK BLVD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4223
Practice Address - Country:US
Practice Address - Phone:276-783-5124
Practice Address - Fax:276-783-2170
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010048491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice