Healthcare Provider Details

I. General information

NPI: 1215046909
Provider Name (Legal Business Name): BRIAN LEE CILLA DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3145 PRAIRIE ST SW SUITE 104
GRANDVILLE MI
49418-2098
US

IV. Provider business mailing address

3145 PRAIRIE ST SW SUITE 104
GRANDVILLE MI
49418-2098
US

V. Phone/Fax

Practice location:
  • Phone: 616-531-1920
  • Fax: 616-531-4275
Mailing address:
  • Phone: 616-531-1920
  • Fax: 616-531-4275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number290104700
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: