Healthcare Provider Details

I. General information

NPI: 1033603030
Provider Name (Legal Business Name): MARCUS RYAN GILLON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N LINDSAY ST
HIGH POINT NC
27262-3903
US

IV. Provider business mailing address

901 N LINDSAY ST
HIGH POINT NC
27262-3903
US

V. Phone/Fax

Practice location:
  • Phone: 336-884-8771
  • Fax: 336-884-8770
Mailing address:
  • Phone: 336-884-8771
  • Fax: 336-884-8770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11321
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number018.002071
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: