Provider Demographics
NPI:1972992162
Name:GILLIS FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GILLIS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-995-6933
Mailing Address - Street 1:2000 N GAINES DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-1132
Mailing Address - Country:US
Mailing Address - Phone:660-885-6933
Mailing Address - Fax:660-885-6935
Practice Address - Street 1:2000 N GAINES DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1132
Practice Address - Country:US
Practice Address - Phone:660-885-6933
Practice Address - Fax:660-885-6935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080168921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty