Provider Demographics
NPI:1104202936
Name:SMITH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25791 E SMOKY HILL ROAD
Mailing Address - Street 2:STE 10
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25791 E SMOKY HILL ROAD
Practice Address - Street 2:STE 10
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016
Practice Address - Country:US
Practice Address - Phone:303-699-3221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002026291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice