Provider Demographics
NPI:1245202670
Name:KELLY, LISA D (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:D
Last Name:KELLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:K
Other - Last Name:FLEMING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:4072 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701-2820
Mailing Address - Country:US
Mailing Address - Phone:757-465-3834
Mailing Address - Fax:
Practice Address - Street 1:4072 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-2820
Practice Address - Country:US
Practice Address - Phone:757-465-3834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010085641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice