Provider Demographics
NPI:1346625431
Name:WHITELEY, KELLY WALSH (DMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:WALSH
Last Name:WHITELEY
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 1:450 NEW MARKET BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5501
Mailing Address - Country:US
Mailing Address - Phone:828-265-1112
Mailing Address - Fax:
Practice Address - Street 1:450 NEW MARKET BLVD STE 2
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607
Practice Address - Country:US
Practice Address - Phone:828-265-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6777122300000X
NC109591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist