Provider Demographics
NPI:1164092680
Name:CREEL, KELLI DIANE
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:DIANE
Last Name:CREEL
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 1:11138 HUEBNER OAKS APT 403
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1279
Mailing Address - Country:US
Mailing Address - Phone:409-673-0156
Mailing Address - Fax:
Practice Address - Street 1:11831 CULEBRA RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-4578
Practice Address - Country:US
Practice Address - Phone:210-625-5353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37335122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist