Provider Demographics
NPI:1255853313
Name:BROOKS, KELLI ELISE (DDS)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ELISE
Last Name:BROOKS
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 1:389 AMERICAN WAY
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062
Mailing Address - Country:US
Mailing Address - Phone:304-748-4210
Mailing Address - Fax:
Practice Address - Street 1:389 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062
Practice Address - Country:US
Practice Address - Phone:304-748-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4272122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist