=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710001797
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL J KILLEBREW DDS & ASSOCIATES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 03/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 63675 E SADDLEBROOKE BLVD STE. M
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85739-1297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-818-6732
-----------------------------------------------------
Fax | 520-818-7824
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8753 E HONEYBEAR PL
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85749-8202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-401-4191
-----------------------------------------------------
Fax | 520-760-0859
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL J KILLEBREW
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 520-401-4191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 2339
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------