Provider Demographics
NPI:1114574100
Name:MAYBERRY, KELLEY MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:MARIE
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4038 THOMAS NELSON HWY
Mailing Address - Street 2:
Mailing Address - City:ARRINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22922-2302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4038 THOMAS NELSON HWY
Practice Address - Street 2:
Practice Address - City:ARRINGTON
Practice Address - State:VA
Practice Address - Zip Code:22922-2302
Practice Address - Country:US
Practice Address - Phone:434-263-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04022078541223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health