Provider Demographics
NPI:1134681661
Name:KILLEEN, MARGARET BRENNAN (DMD)
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:BRENNAN
Last Name:KILLEEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E CHESTNUT ST APT 421
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2311
Mailing Address - Country:US
Mailing Address - Phone:216-386-7653
Mailing Address - Fax:
Practice Address - Street 1:811 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5123
Practice Address - Country:US
Practice Address - Phone:773-871-1461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL319.0215831223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program