Provider Demographics
NPI:1215605415
Name:KELLEY, AHNA SYMONE (DDS)
Entity Type:Individual
Prefix:DR
First Name:AHNA
Middle Name:SYMONE
Last Name:KELLEY
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 1:3646 EAGLE RISE
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3541
Mailing Address - Country:US
Mailing Address - Phone:678-643-3842
Mailing Address - Fax:
Practice Address - Street 1:5295 STONE MOUNTAIN HWY STE K
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3439
Practice Address - Country:US
Practice Address - Phone:770-465-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122485122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist