Provider Demographics
NPI:1962669200
Name:DILLLARD, MICHAEL SHANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANE
Last Name:DILLLARD
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 1:9492 GREENS MILL CT
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5265
Mailing Address - Country:US
Mailing Address - Phone:770-264-7951
Mailing Address - Fax:
Practice Address - Street 1:2400 WISTERIA DR STE D
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2689
Practice Address - Country:US
Practice Address - Phone:770-979-7794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0137091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice