MEDICARE: TILLMAN DENTAL & ORTHODONTICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	23294	TX

General Provider Information

NPI Number	:	1093951626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TILLMAN DENTAL & ORTHODONTICS

Provider Business Mailing Address
First Line	:	5701 KIAM ST UNIT F
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-1141
Country	:	US
Telephone Number	:	713-294-5774
Fax Number	:

Provider Business Practice Location Address
First Line	:	2280 HOLCOMBE BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-4224
Country	:	US
Telephone Number	:	713-799-1400
Fax Number	:	713-799-1751

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. DEREK TILLMAN
Credential	:	D.M.D.
Telephone Number	:	713-294-5774

Provider Enumeration Date	:	01/03/2009
Last Update Date	:	01/03/2009

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