Healthcare Provider Details

I. General information

NPI: 1760637243
Provider Name (Legal Business Name): DAVID G DILLARD, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

771 OLD NORCROSS RD SUITE 140
LAWRENCEVILLE GA
30045-4317
US

IV. Provider business mailing address

PO BOX 1728
WATKINSVILLE GA
30677-0034
US

V. Phone/Fax

Practice location:
  • Phone: 678-689-1100
  • Fax: 678-689-1104
Mailing address:
  • Phone: 706-310-0252
  • Fax: 706-769-2750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number040364
License Number StateGU

VIII. Authorized Official

Name: DAVID G DILLARD
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 678-689-1100