Healthcare Provider Details

I. General information

NPI: 1417165838
Provider Name (Legal Business Name): GREG A KILLIAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6213 MIDDLETON SPRINGS DR SUITE 104
MIDDLETON WI
53562-2273
US

IV. Provider business mailing address

6213 MIDDLETON SPRINGS DR SUITE 104
MIDDLETON WI
53562-2273
US

V. Phone/Fax

Practice location:
  • Phone: 608-831-0467
  • Fax: 608-831-5108
Mailing address:
  • Phone: 608-831-0467
  • Fax: 608-831-5108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2108G-WI
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: