Provider Demographics
NPI:1073737748
Name:SCANLON-CHASE, KELLY ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:SCANLON-CHASE
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 1:2377 BOSTON RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1254
Mailing Address - Country:US
Mailing Address - Phone:413-596-6444
Mailing Address - Fax:413-596-6237
Practice Address - Street 1:2377 BOSTON RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WILBRAHAM
Practice Address - State:MA
Practice Address - Zip Code:01095-1254
Practice Address - Country:US
Practice Address - Phone:413-596-6444
Practice Address - Fax:413-596-6237
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA179561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1053350470OtherNPI-BOULDER BROOK DENTAL