Provider Demographics
NPI:1083834063
Name:SPILLANE, KEVIN T (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:T
Last Name:SPILLANE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:335 PARKWAY 575
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6433
Mailing Address - Country:US
Mailing Address - Phone:770-928-4747
Mailing Address - Fax:770-928-0670
Practice Address - Street 1:335 PARKWAY 575
Practice Address - Street 2:SUITE 200
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6433
Practice Address - Country:US
Practice Address - Phone:770-928-4747
Practice Address - Fax:770-928-0670
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA102461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics