Healthcare Provider Details

I. General information

NPI: 1225148273
Provider Name (Legal Business Name): KEVIN MICHAEL KILLIAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 SALT LICK RD
SAINT PETERS MO
63376-1170
US

IV. Provider business mailing address

625 SALT LICK RD
SAINT PETERS MO
63376-1170
US

V. Phone/Fax

Practice location:
  • Phone: 636-970-2699
  • Fax: 636-279-1853
Mailing address:
  • Phone: 636-970-2699
  • Fax: 636-279-1853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number014633
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: