Provider Demographics
NPI:1124183330
Name:MCDERMOTT, KELLY HARTNETT (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:HARTNETT
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:HARTNETT
Other - Last Name:MCDERMOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:111 GASLIGHT BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3188
Mailing Address - Country:US
Mailing Address - Phone:936-634-8201
Mailing Address - Fax:936-639-2187
Practice Address - Street 1:111 GASLIGHT BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3188
Practice Address - Country:US
Practice Address - Phone:936-634-8201
Practice Address - Fax:936-639-2187
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175004401Medicaid