Provider Demographics
NPI:1033525431
Name:PAUL KELLUM, DDS
Entity Type:Organization
Organization Name:PAUL KELLUM, DDS
Other - Org Name:DESTIN DENTAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:850-837-6645
Mailing Address - Street 1:985 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2835
Mailing Address - Country:US
Mailing Address - Phone:850-837-6645
Mailing Address - Fax:850-650-8553
Practice Address - Street 1:985 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2835
Practice Address - Country:US
Practice Address - Phone:850-837-6645
Practice Address - Fax:850-650-8553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10931261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental