Provider Demographics
NPI:1215364252
Name:KELLY F. VIAU, D.D.S., P.A.
Entity Type:Organization
Organization Name:KELLY F. VIAU, D.D.S., P.A.
Other - Org Name:PEAK CITY FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:FRYE
Authorized Official - Last Name:VIAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-362-8797
Mailing Address - Street 1:103 N SALEM ST
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-1427
Mailing Address - Country:US
Mailing Address - Phone:919-362-8797
Mailing Address - Fax:919-362-1476
Practice Address - Street 1:103 N SALEM ST
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-1427
Practice Address - Country:US
Practice Address - Phone:919-362-8797
Practice Address - Fax:919-362-1476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-05
Last Update Date:2013-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8245122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904125Medicaid