Provider Demographics
NPI:1770117954
Name:DILLARD, MARLIN L
Entity type:Individual
Prefix:
First Name:MARLIN
Middle Name:L
Last Name:DILLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5103 BELLEFONTAINE RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-4163
Mailing Address - Country:US
Mailing Address - Phone:937-405-3336
Mailing Address - Fax:
Practice Address - Street 1:5103 BELLEFONTAINE RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-4163
Practice Address - Country:US
Practice Address - Phone:937-405-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRS525863405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional