Provider Demographics
NPI:1902020118
Name:TILLERY GROUP PA
Entity Type:Organization
Organization Name:TILLERY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:E
Authorized Official - Last Name:TILLERY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-628-5400
Mailing Address - Street 1:800 W MORSE BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3797
Mailing Address - Country:US
Mailing Address - Phone:407-628-5400
Mailing Address - Fax:407-628-5389
Practice Address - Street 1:800 W MORSE BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3797
Practice Address - Country:US
Practice Address - Phone:407-628-5400
Practice Address - Fax:407-628-5389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101781223S0112X
FL161031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL67930Medicare ID - Type Unspecified