Provider Demographics
NPI:1669630489
Name:BRIAN CILLA DDS MS PC
Entity Type:Organization
Organization Name:BRIAN CILLA DDS MS PC
Other - Org Name:WEST MICHIGAN PERIODONTICS & ADVANCED IMPLANT DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:616-531-1920
Mailing Address - Street 1:3145 PRAIRIE ST SW
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418
Mailing Address - Country:US
Mailing Address - Phone:616-531-1920
Mailing Address - Fax:616-531-4275
Practice Address - Street 1:3145 PRAIRIE ST SW
Practice Address - Street 2:SUITE 104
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418
Practice Address - Country:US
Practice Address - Phone:616-531-1920
Practice Address - Fax:616-531-4275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901047001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty