Provider Demographics
NPI:1962569400
Name:TILLER, ERNEST JOSEPH JR (DDS)
Entity type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:JOSEPH
Last Name:TILLER
Suffix:JR
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 1:2341 HENRY CLOWER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-7420
Mailing Address - Country:US
Mailing Address - Phone:770-736-0099
Mailing Address - Fax:770-923-9219
Practice Address - Street 1:2341 HENRY CLOWER BLVD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7420
Practice Address - Country:US
Practice Address - Phone:770-736-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0132691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice