Healthcare Provider Details

I. General information

NPI: 1871856617
Provider Name (Legal Business Name): MELVIN LAUREL DILLARD III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1964 DEMPSTER ST
EVANSTON IL
60202-1016
US

IV. Provider business mailing address

1964 DEMPSTER ST
EVANSTON IL
60202-1016
US

V. Phone/Fax

Practice location:
  • Phone: 773-608-9334
  • Fax:
Mailing address:
  • Phone: 773-608-9334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.028872
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN1000944
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021002650
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6916-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: