Provider Demographics
NPI:1295027993
Name:NIX, KELLY S (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:NIX
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 FM 300
Mailing Address - Street 2:
Mailing Address - City:LEVELLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79336-6235
Mailing Address - Country:US
Mailing Address - Phone:806-894-7842
Mailing Address - Fax:806-894-3378
Practice Address - Street 1:1000 FM 300
Practice Address - Street 2:
Practice Address - City:LEVELLAND
Practice Address - State:TX
Practice Address - Zip Code:79336-6235
Practice Address - Country:US
Practice Address - Phone:806-894-7842
Practice Address - Fax:806-894-3378
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4498124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121513902Medicaid