Provider Demographics
NPI:1316135452
Name:TILLNER, JOHN EMERY JR (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EMERY
Last Name:TILLNER
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:752 MEDICAL CENTER CT
Mailing Address - Street 2:#205
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6658
Mailing Address - Country:US
Mailing Address - Phone:619-482-6774
Mailing Address - Fax:619-482-7637
Practice Address - Street 1:752 MEDICAL CENTER CT
Practice Address - Street 2:#205
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6658
Practice Address - Country:US
Practice Address - Phone:619-482-6774
Practice Address - Fax:619-482-7637
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA529441223S0112X
IL0210023361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery