Provider Demographics
NPI:1053503573
Name:CARLEN, KELLY E (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:E
Last Name:CARLEN
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 1:2811 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8482
Mailing Address - Country:US
Mailing Address - Phone:208-461-1060
Mailing Address - Fax:
Practice Address - Street 1:2811 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8482
Practice Address - Country:US
Practice Address - Phone:208-461-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3271122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist