Provider Demographics
NPI:1528078227
Name:KILLGORE, ANDREW MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MICHAEL
Last Name:KILLGORE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 EASTGATE SOUTH DR STE 250
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-1563
Mailing Address - Country:US
Mailing Address - Phone:513-633-3857
Mailing Address - Fax:
Practice Address - Street 1:792 EASTGATE SOUTH DR STE 250
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1563
Practice Address - Country:US
Practice Address - Phone:513-633-3857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79133282Medicaid