Provider Demographics
NPI:1174636286
Name:FARIS, KELLEY D (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:D
Last Name:FARIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W MCDONALD PKWY
Mailing Address - Street 2:SUITE 2-D
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-1164
Mailing Address - Country:US
Mailing Address - Phone:606-564-6852
Mailing Address - Fax:606-564-8119
Practice Address - Street 1:1 W MCDONALD PKWY
Practice Address - Street 2:SUITE 2-D
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-1164
Practice Address - Country:US
Practice Address - Phone:606-564-6852
Practice Address - Fax:606-564-8119
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY69111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY69119002Medicaid
KY1375487OtherBLUE CROSS BLUE SHIELD