Provider Demographics
NPI:1265726921
Name:LILLAND, KRYSTA LEIGH (DDS)
Entity type:Individual
Prefix:DR
First Name:KRYSTA
Middle Name:LEIGH
Last Name:LILLAND
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2133
Mailing Address - Country:US
Mailing Address - Phone:630-377-3131
Mailing Address - Fax:630-377-3204
Practice Address - Street 1:516 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2133
Practice Address - Country:US
Practice Address - Phone:630-377-3131
Practice Address - Fax:630-377-3204
Is Sole Proprietor?:No
Enumeration Date:2011-05-30
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190289551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice