MEDICARE: DR. COURTNEY ELLEN KILLOUGH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401416034	VA
2	1223G0001X	General Practice Dentistry	DDS104474	CA

General Provider Information

NPI Number	:	1619467479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COURTNEY ELLEN KILLOUGH DDS

Provider Business Mailing Address
First Line	:	1953 DRY CREEK RD
Second Line	:
City	:	CAMPBELL
State	:	CA
Zip	:	95008-3629
Country	:	US
Telephone Number	:	757-320-9303
Fax Number	:

Provider Business Practice Location Address
First Line	:	18455 TECHNOLOGY DR
Second Line	:
City	:	MORGAN HILL
State	:	CA
Zip	:	95037-2822
Country	:	US
Telephone Number	:	408-778-4838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2018
Last Update Date	:	04/09/2022

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