Provider Demographics
NPI:1871856617
Name:DILLARD, MELVIN LAUREL III (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:LAUREL
Last Name:DILLARD
Suffix:III
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 1:1964 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1016
Mailing Address - Country:US
Mailing Address - Phone:773-608-9334
Mailing Address - Fax:
Practice Address - Street 1:1964 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1016
Practice Address - Country:US
Practice Address - Phone:773-608-9334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210026501223X0400X
IL019.028872122300000X
DCDEN1000944122300000X
WI6916-151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist