Provider Demographics
NPI:1710176086
Name:ROBERT E. GILLIS, JR, DMD, MSD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ROBERT E. GILLIS, JR, DMD, MSD, A PROFESSIONAL CORPORATION
Other - Org Name:ROBERT E. GILLIS, JR, DMD, MSD, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-731-5778
Mailing Address - Street 1:3000 L ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5248
Mailing Address - Country:US
Mailing Address - Phone:916-731-5778
Mailing Address - Fax:
Practice Address - Street 1:3000 L ST STE 205
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5248
Practice Address - Country:US
Practice Address - Phone:916-731-5778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220701223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2207001Medicaid
CAB2207001Medicaid
T08304Medicare UPIN