Provider Demographics
NPI:1962554204
Name:GILLUM, RICHARD S (DDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
Last Name:GILLUM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1259 N STATE ROAD 135
Mailing Address - Street 2:SUITE E
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1033
Mailing Address - Country:US
Mailing Address - Phone:317-888-7576
Mailing Address - Fax:317-888-0047
Practice Address - Street 1:1259 N STATE ROAD 135
Practice Address - Street 2:SUITE E
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1033
Practice Address - Country:US
Practice Address - Phone:317-888-7576
Practice Address - Fax:317-888-0047
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120085731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice