Healthcare Provider Details

I. General information

NPI: 1689686255
Provider Name (Legal Business Name): AMY MARIE KILLEEN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29A WEST PENNSYLVANIA AVENUE
WALKERSVILLE MD
21793
US

IV. Provider business mailing address

PO BOX 608
WALKERSVILLE MD
21793-0608
US

V. Phone/Fax

Practice location:
  • Phone: 301-898-5778
  • Fax: 301-898-5350
Mailing address:
  • Phone: 301-898-5778
  • Fax: 301-898-5350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8495
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: