Provider Demographics
NPI:1053676734
Name:KELLEY, GRETCHEN MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:MARIE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9501 PASEO DEL NORTE NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2999
Mailing Address - Country:US
Mailing Address - Phone:505-369-1881
Mailing Address - Fax:505-369-1882
Practice Address - Street 1:9501 PASEO DEL NORTE NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2999
Practice Address - Country:US
Practice Address - Phone:505-369-1881
Practice Address - Fax:505-369-1882
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD37091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice