Provider Demographics
NPI:1114089067
Name:AXELRAD, KELLIE SCOTT (DDS)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:SCOTT
Last Name:AXELRAD
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 1:6435 CANAL BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-3119
Mailing Address - Country:US
Mailing Address - Phone:504-628-7625
Mailing Address - Fax:
Practice Address - Street 1:6264 CANAL BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70124-3030
Practice Address - Country:US
Practice Address - Phone:504-833-5528
Practice Address - Fax:504-833-5542
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5545122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1855456Medicaid