Healthcare Provider Details

I. General information

NPI: 1710111083
Provider Name (Legal Business Name): CHAD M ZILLICH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 S BEECHTREE ST
GRAND HAVEN MI
49417-2839
US

IV. Provider business mailing address

13376 GREENLEAF LN
GRAND HAVEN MI
49417-9453
US

V. Phone/Fax

Practice location:
  • Phone: 734-548-0059
  • Fax:
Mailing address:
  • Phone: 734-548-0059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN - 10260
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number290120018
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN013917
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: