Provider Demographics
NPI:1770661951
Name:LILLY FAMILY DENTISTRY, P.C.
Entity Type:Organization
Organization Name:LILLY FAMILY DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-239-5125
Mailing Address - Street 1:2100 INDIAN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-1604
Mailing Address - Country:US
Mailing Address - Phone:712-239-5125
Mailing Address - Fax:712-239-2275
Practice Address - Street 1:2100 INDIAN HILLS DR
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-1604
Practice Address - Country:US
Practice Address - Phone:712-239-5125
Practice Address - Fax:712-239-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA75771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1106369Medicaid
IA1106369Medicaid