1740452465 NPI number — DIANE C KELLY DMD, PC

Table of content: (NPI 1740452465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740452465 NPI number — DIANE C KELLY DMD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIANE C KELLY DMD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHILDRENS DENTISTRY AT HAMILTON MILL & GAINESVILLE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740452465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 JESSE JEWELL PKWY SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-539-9110
Provider Business Mailing Address Fax Number:
678-714-8388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 JESSE JEWELL PKWY SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-539-9110
Provider Business Practice Location Address Fax Number:
678-714-8388
Provider Enumeration Date:
04/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER - AND PROVIDER
Authorized Official Telephone Number:
678-714-7011

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  DNO12082 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 186794814A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 191450941A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 390489607J , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000046582Y , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 919057925B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 514725717B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000851727B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 609963109E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 218323780A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 609963109L , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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