Healthcare Provider Details

I. General information

NPI: 1316135452
Provider Name (Legal Business Name): JOHN EMERY TILLNER JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

752 MEDICAL CENTER CT #205
CHULA VISTA CA
91911-6658
US

IV. Provider business mailing address

752 MEDICAL CENTER CT #205
CHULA VISTA CA
91911-6658
US

V. Phone/Fax

Practice location:
  • Phone: 619-482-6774
  • Fax: 619-482-7637
Mailing address:
  • Phone: 619-482-6774
  • Fax: 619-482-7637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number52944
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021002336
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: