Provider Demographics
NPI:1205212891
Name:BIDWELL, KELLY (RDH)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:BIDWELL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 TOTEM CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-1973
Mailing Address - Country:US
Mailing Address - Phone:814-602-8028
Mailing Address - Fax:
Practice Address - Street 1:100 OLD CHEROKEE RD
Practice Address - Street 2:SUITE F PMB 14
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9316
Practice Address - Country:US
Practice Address - Phone:800-276-2398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9406124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist