Provider Demographics
NPI:1710074646
Name:TILLMANN, RUEDIGER (DDS)
Entity Type:Individual
Prefix:
First Name:RUEDIGER
Middle Name:
Last Name:TILLMANN
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 1:5872 S 900 E
Mailing Address - Street 2:202
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-1676
Mailing Address - Country:US
Mailing Address - Phone:801-281-8433
Mailing Address - Fax:801-281-8455
Practice Address - Street 1:5872 S 900 E
Practice Address - Street 2:202
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-1676
Practice Address - Country:US
Practice Address - Phone:801-281-8433
Practice Address - Fax:801-281-8455
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1422741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0196OtherALTIUS/MONARCH INSURANCE
TX14705OtherPUBLIC EMPLOYEES INSURAN
KY0005762263OtherAETNA INSURANCE
KY180939232300Medicare UPIN
UT20048Medicare UPIN
UT3723000000122274UTMedicare UPIN
KY0005762263OtherAETNA INSURANCE
TX14705OtherPUBLIC EMPLOYEES INSURAN