Provider Demographics
NPI:1134396914
Name:TILLY, MARYELLEN (RDH BA)
Entity type:Individual
Prefix:MRS
First Name:MARYELLEN
Middle Name:
Last Name:TILLY
Suffix:
Gender:F
Credentials:RDH BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15100 RESCUE WAY
Mailing Address - Street 2:DENTAL
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-3502
Mailing Address - Country:US
Mailing Address - Phone:727-535-1437
Mailing Address - Fax:
Practice Address - Street 1:15100 RESCUE WAY
Practice Address - Street 2:DENTAL
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-3502
Practice Address - Country:US
Practice Address - Phone:727-535-1437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH 11169124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist