Provider Demographics
NPI:1942039201
Name:TOLLISON ORTHO LLC
Entity type:Organization
Organization Name:TOLLISON ORTHO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:TOLLISON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:864-329-1971
Mailing Address - Street 1:20 CREEKVIEW CT STE A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4800
Mailing Address - Country:US
Mailing Address - Phone:864-329-1971
Mailing Address - Fax:864-329-1973
Practice Address - Street 1:20A CREEKVIEW CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4800
Practice Address - Country:US
Practice Address - Phone:864-329-1971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-26
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty