Provider Demographics
NPI:1205197373
Name:DOVE, KELLY DOVE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DOVE
Last Name:DOVE
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 1:725 W. MT. VERNON ST.
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714
Mailing Address - Country:US
Mailing Address - Phone:417-862-2468
Mailing Address - Fax:417-869-2469
Practice Address - Street 1:725 W MT. VERNON ST.
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714
Practice Address - Country:US
Practice Address - Phone:417-708-9098
Practice Address - Fax:417-869-2469
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012055251223G0001X
MO20120155251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice