Provider Demographics
NPI:1801028436
Name:LILLY, ERIC VAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:VAN
Last Name:LILLY
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 1:1108 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-6318
Mailing Address - Country:US
Mailing Address - Phone:336-275-1768
Mailing Address - Fax:
Practice Address - Street 1:1108 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-6318
Practice Address - Country:US
Practice Address - Phone:336-275-1768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-16
Last Update Date:2009-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3578122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist