Provider Demographics
NPI:1225142953
Name:WRIGHT, KELLY A (DMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 S WALTON DR
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504-9396
Mailing Address - Country:US
Mailing Address - Phone:919-894-1612
Mailing Address - Fax:919-894-2556
Practice Address - Street 1:303 S WALTON DR
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504-9396
Practice Address - Country:US
Practice Address - Phone:919-894-1612
Practice Address - Fax:919-894-2556
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC74961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902ERMedicaid
NC89902ERMedicaid