Provider Demographics
NPI:1285724617
Name:KILLGROVE, TIMOTHY J (DDS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:KILLGROVE
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 1:39525 WEST 14 MILE ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1638
Mailing Address - Country:US
Mailing Address - Phone:248-624-2951
Mailing Address - Fax:248-624-4741
Practice Address - Street 1:39525 WEST 14 MILE ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1638
Practice Address - Country:US
Practice Address - Phone:248-624-2951
Practice Address - Fax:248-624-4741
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16367122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist