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General NPI Number Information
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NPI Number | 1902020118
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Entity Type | Organization
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Legal Business Name | TILLERY GROUP PA
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 09/23/2014
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Provider Practice Location Address
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Address Line | 800 W MORSE BLVD SUITE 2
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City | WINTER PARK
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State | FL
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Zip | 32789-3797
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Country | US
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Telephone | 407-628-5400
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Fax | 407-628-5389
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Provider Business Mailing Address
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Address Line | 800 W MORSE BLVD SUITE 2
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City | WINTER PARK
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State | FL
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Zip | 32789-3797
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Country | US
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Telephone | 407-628-5400
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Fax | 407-628-5389
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Authorized Official
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Title or Position | OWNER AND SURGEON
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Name | DR. DON E TILLERY JR.
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Credential | DMD
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Telephone | 407-628-5400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 16103
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 10178
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License Number State | FL
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