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NPI Code Detail

MEDICARE: TILLERY DENTAL CLINICS, P.A.

MEDICARE: TILLERY DENTAL CLINICS, P.A.
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
11223G0001XGeneral Practice DentistryMS133268MS

General Provider Information

NPI Number : 1376656041
Entity Type Code : Organization
Provider Name (Legal Business Name) : TILLERY DENTAL CLINICS, P.A.
Provider Business Mailing Address
First Line : 1508 W 10TH ST
Second Line :
City : LAUREL
State : MS
Zip : 39440-2668
Country : US
Telephone Number : 601-428-6093
Fax Number : 601-428-6096
Provider Business Practice Location Address
First Line : 1508 W 10TH ST
Second Line :
City : LAUREL
State : MS
Zip : 39440-2668
Country : US
Telephone Number : 601-428-6093
Fax Number : 601-428-6096
Authorized Official
Title or Position : OWNER
Name : DOUGLAS W. TILLERY
Credential :
Telephone Number : 601-428-6093
Provider Enumeration Date : 08/16/2006
Last Update Date : 01/03/2008

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