Healthcare Provider Details

I. General information

NPI: 1609438803
Provider Name (Legal Business Name): MICHAEL JOSEPH LILLY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 RENO DR
WAYLAND MI
49348-1732
US

IV. Provider business mailing address

1402 SILVER SPRINGS CT SE
CALEDONIA MI
49316-8445
US

V. Phone/Fax

Practice location:
  • Phone: 269-509-4155
  • Fax:
Mailing address:
  • Phone: 989-330-5243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901600219
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: