Provider Demographics
NPI:1215046909
Name:CILLA, BRIAN LEE (DDS MS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
Last Name:CILLA
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:49418-2098
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:49418-2098
Practice Address - Country:US
Practice Address - Phone:616-531-1920
Practice Address - Fax:616-531-4275
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901047001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics