Provider Demographics
NPI:1609971928
Name:KILLIAN, BRYCE CHRISTOFER (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:CHRISTOFER
Last Name:KILLIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:PAUL
Mailing Address - State:ID
Mailing Address - Zip Code:83347-0549
Mailing Address - Country:US
Mailing Address - Phone:208-438-4855
Mailing Address - Fax:208-438-4835
Practice Address - Street 1:207 W. ELLIS ST.
Practice Address - Street 2:
Practice Address - City:PAUL
Practice Address - State:ID
Practice Address - Zip Code:83347
Practice Address - Country:US
Practice Address - Phone:208-438-4855
Practice Address - Fax:208-438-4835
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-32721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice