Provider Demographics
NPI:1265094460
Name:LILLY, CLAIRE KITTAKA (DMD)
Entity type:Individual
Prefix:DR
First Name:CLAIRE
Middle Name:KITTAKA
Last Name:LILLY
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 1:201 FULTON ST W APT 1416
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2678
Mailing Address - Country:US
Mailing Address - Phone:317-697-7702
Mailing Address - Fax:
Practice Address - Street 1:899 RENO DR
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-1732
Practice Address - Country:US
Practice Address - Phone:269-509-4155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600222122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist