Provider Demographics
NPI:1790728236
Name:TILLIS, JOHN BARRY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BARRY
Last Name:TILLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7117 CRIMSON RIDGE DR.
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107
Mailing Address - Country:US
Mailing Address - Phone:815-395-0327
Mailing Address - Fax:
Practice Address - Street 1:7117 CRIMSON RIDGE DR
Practice Address - Street 2:SUITE 5
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6208
Practice Address - Country:US
Practice Address - Phone:815-395-0327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-019019783122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist