Provider Demographics
NPI:1033561535
Name:EBERHARDT, KELLI ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:ELIZABETH
Last Name:EBERHARDT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28485 ALTESSA WAY
Mailing Address - Street 2:#102
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-6976
Mailing Address - Country:US
Mailing Address - Phone:239-287-6473
Mailing Address - Fax:
Practice Address - Street 1:25195 CHAMBER OF COMMERCE DR
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-7895
Practice Address - Country:US
Practice Address - Phone:239-947-7481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22050122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist