Provider Demographics
NPI:1649657255
Name:MELVIN AND JAZMINE DILLARD DDS, PC
Entity type:Organization
Organization Name:MELVIN AND JAZMINE DILLARD DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-563-4484
Mailing Address - Street 1:1964 DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1964 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1016
Practice Address - Country:US
Practice Address - Phone:312-600-8119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029481122300000X
IL0210026501223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty