Healthcare Provider Details

I. General information

NPI: 1710001797
Provider Name (Legal Business Name): MICHAEL J KILLEBREW DDS & ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63675 E SADDLEBROOKE BLVD STE. M
TUCSON AZ
85739-1297
US

IV. Provider business mailing address

8753 E HONEYBEAR PL
TUCSON AZ
85749-8202
US

V. Phone/Fax

Practice location:
  • Phone: 520-818-6732
  • Fax: 520-818-7824
Mailing address:
  • Phone: 520-401-4191
  • Fax: 520-760-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2339
License Number StateAZ

VIII. Authorized Official

Name: DR. MICHAEL J KILLEBREW
Title or Position: PRESIDENT
Credential: DDS
Phone: 520-401-4191