Provider Demographics
NPI:1811156839
Name:DILLON, JERRY WAYNE (DDS, MS, PHD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:DILLON
Suffix:
Gender:M
Credentials:DDS, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1355
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-1355
Mailing Address - Country:US
Mailing Address - Phone:708-862-1800
Mailing Address - Fax:708-862-5098
Practice Address - Street 1:2000 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5074
Practice Address - Country:US
Practice Address - Phone:708-862-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190226221223G0001X, 1223P0300X
MS2539-901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0300XDental ProvidersDentistPeriodontics