MEDICARE: DR. MICHAEL DAVID TILLMAN DDS

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	1223G0001X	General Practice Dentistry	16464	TX

General Provider Information

NPI Number	:	1316148471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL DAVID TILLMAN DDS

Provider Business Mailing Address
First Line	:	747 8TH AVE
Second Line	:	STE C
City	:	FT WORTH
State	:	TX
Zip	:	76104
Country	:	US
Telephone Number	:	817-332-9303
Fax Number	:	817-332-6559

Provider Business Practice Location Address
First Line	:	747 8TH AVE STE C
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76104-2503
Country	:	US
Telephone Number	:	817-332-9303
Fax Number	:	817-332-6559

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	07/08/2007

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