Provider Demographics
NPI:1780910026
Name:MARTIN G. TILLEY D.D.S., M.D., P.C.
Entity type:Organization
Organization Name:MARTIN G. TILLEY D.D.S., M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:TILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS PC
Authorized Official - Phone:308-865-2577
Mailing Address - Street 1:516 W 39TH ST
Mailing Address - Street 2:SUITE D TOWER PLAZA
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2881
Mailing Address - Country:US
Mailing Address - Phone:308-865-2577
Mailing Address - Fax:
Practice Address - Street 1:516 W 39TH ST
Practice Address - Street 2:SUITE D TOWER PLAZA
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2881
Practice Address - Country:US
Practice Address - Phone:308-865-2577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTIN G. TILLEY D.D.S., M.D., P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-21
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3663OtherBLUE CROSS BLUE SHIELD
5400OtherBLUE CROSS BLUE SHIELD
NE01Medicaid
NED80362Medicare UPIN
3663OtherBLUE CROSS BLUE SHIELD