Provider Demographics
NPI:1093826323
Name:KELLY, MARIE PETTERS (DDS)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:PETTERS
Last Name:KELLY
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 1:1670 LINCOLN HWY E
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2663
Mailing Address - Country:US
Mailing Address - Phone:717-394-1067
Mailing Address - Fax:
Practice Address - Street 1:1670 LINCOLN HWY E
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2663
Practice Address - Country:US
Practice Address - Phone:717-394-1067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC75831223G0001X
PADS025788L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS025788LOtherPA DENTIST LICENSE