Healthcare Provider Details

I. General information

NPI: 1932384393
Provider Name (Legal Business Name): KEVIN M. KILLIAN, D.D.S.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2008
Last Update Date: 01/04/2008
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:
Mailing address:
  • Phone: 636-970-2699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number14633
License Number StateMO

VIII. Authorized Official

Name: DR. KEVIN M. KILLIAN
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 636-970-2699