Provider Demographics
NPI:1083144265
Name:WESSEL, KELLY (DMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WESSEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BEGLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4413 SANTA PAULA LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-3820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4413 SANTA PAULA LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3820
Practice Address - Country:US
Practice Address - Phone:859-739-0423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY99761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry