Provider Demographics
NPI:1538474986
Name:ZILLICH, IRENE SEA HADDOCK (DDS)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:SEA HADDOCK
Last Name:ZILLICH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:SEA
Other - Last Name:HADDOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1793 W STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5288
Mailing Address - Country:US
Mailing Address - Phone:734-662-3222
Mailing Address - Fax:
Practice Address - Street 1:1793 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5288
Practice Address - Country:US
Practice Address - Phone:734-662-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020004122300000X
CODEN-10206122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist