Provider Demographics
NPI:1073727491
Name:LARRABEE - DEWELL, KELLI (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:
Last Name:LARRABEE - DEWELL
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 1:5957 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MC CORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-9355
Mailing Address - Country:US
Mailing Address - Phone:317-402-8521
Mailing Address - Fax:
Practice Address - Street 1:5957 W BROADWAY
Practice Address - Street 2:
Practice Address - City:MC CORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-9355
Practice Address - Country:US
Practice Address - Phone:317-402-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010860A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200845770Medicaid