1609971928 NPI number — DR. BRYCE CHRISTOFER KILLIAN D.D.S.

Table of content: DR. BRYCE CHRISTOFER KILLIAN D.D.S. (NPI 1609971928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609971928 NPI number — DR. BRYCE CHRISTOFER KILLIAN D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILLIAN
Provider First Name:
BRYCE
Provider Middle Name:
CHRISTOFER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609971928
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAUL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83347-0549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-438-4855
Provider Business Mailing Address Fax Number:
208-438-4835

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 W. ELLIS ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAUL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-438-4855
Provider Business Practice Location Address Fax Number:
208-438-4835
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D-3272 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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