Provider Demographics
NPI:1184851867
Name:LAST, KELLY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:S
Last Name:LAST
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 1:3092 EVERGREEN PKWY
Mailing Address - Street 2:#100
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7849
Mailing Address - Country:US
Mailing Address - Phone:303-674-6264
Mailing Address - Fax:
Practice Address - Street 1:3092 EVERGREEN PKWY
Practice Address - Street 2:#100
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7849
Practice Address - Country:US
Practice Address - Phone:303-674-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9378122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist