Provider Demographics
NPI:1306009881
Name:DEZURA, KELLY ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:DEZURA
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 1:3717 NE 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-1241
Mailing Address - Country:US
Mailing Address - Phone:419-306-6443
Mailing Address - Fax:
Practice Address - Street 1:10181 SE SUNNYSIDE RD
Practice Address - Street 2:OTOLARYNGOLOGY (ENT)
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:510-571-4727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-06
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD98581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery