Active NPI
Connie Bruce Gilliam, D.D.S.
- Pediatric Dentistry
- Jacksonville, NC
National Provider Identifier
1548460298
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- 6034
- Practice address
- 2 Office Park Dr
Jacksonville, NC 28546-7325 - Phone
- (910) 577-5077
- Fax
- (910) 577-1907
- NPI assigned
- Jul 20, 2007
- Last updated
- Oct 31, 2023
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 6034 | NC | Primary |
Addresses
Primary practice location
2 Office Park Dr
Jacksonville, NC 28546-7325
Mailing address
2 Office Park Dr
Jacksonville, NC 28546-7325
Phone (910) 577-5077
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 060913 | Other | NC | UNITED CONCORDIA |
| 8993221 | Medicaid | NC | |
| 014CY | Other | NC | BCBS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6034 | NC | MD | Chiropractor |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Gilliam & Gilliam PLLC | Pediatric Dentistry | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Pediatric Dentistry
- Jacksonville, NC
- NPI 1174635882
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1184889600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1698710400000",
"number": "1548460298",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2 OFFICE PARK DR",
"city": "JACKSONVILLE",
"state": "NC",
"postal_code": "285467325",
"telephone_number": "910-577-5077",
"fax_number": "910-577-1907"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2 OFFICE PARK DR",
"city": "JACKSONVILLE",
"state": "NC",
"postal_code": "285467325",
"telephone_number": "910-577-5077",
"fax_number": "910-577-1907"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BRUCE GILLIAM",
"first_name": "CONNIE",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-07-20",
"last_updated": "2023-10-31",
"certification_date": "2023-10-31",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "NC",
"license": "6034",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNITED CONCORDIA",
"identifier": "060913",
"state": "NC"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "8993221",
"state": "NC"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "014CY",
"state": "NC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Jacksonville, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.