Provider Demographics
NPI:1275197006
Name:MCCALL, KELLY ANN (RDH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:MCCALL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:WALSH
Mailing Address - State:CO
Mailing Address - Zip Code:81090
Mailing Address - Country:US
Mailing Address - Phone:719-691-5770
Mailing Address - Fax:
Practice Address - Street 1:137 N. KANSAS ST
Practice Address - Street 2:
Practice Address - City:WALSH
Practice Address - State:CO
Practice Address - Zip Code:81090
Practice Address - Country:US
Practice Address - Phone:719-324-5251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002025113124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist