Healthcare Provider Details

I. General information

NPI: 1205415536
Provider Name (Legal Business Name): DILLON CLANCY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 MADISON AVE
MOUNT HOLLY NJ
08060-2099
US

IV. Provider business mailing address

1501 LITTLE GLOUCESTER RD APT E28
BLACKWOOD NJ
08012-3441
US

V. Phone/Fax

Practice location:
  • Phone: 609-914-6000
  • Fax:
Mailing address:
  • Phone: 631-379-3105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: