Provider Demographics
NPI:1316039324
Name:KELLY, GWENDOLYN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:A
Last Name:KELLY
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 1:101 N LA BREA AVE
Mailing Address - Street 2:SUITE 506
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1769
Mailing Address - Country:US
Mailing Address - Phone:310-412-9291
Mailing Address - Fax:310-412-1705
Practice Address - Street 1:101 N LA BREA AVE
Practice Address - Street 2:SUITE 506
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1769
Practice Address - Country:US
Practice Address - Phone:310-412-9291
Practice Address - Fax:310-412-1705
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice