Provider Demographics
NPI:1407330913
Name:KELLY, COURTNEY PARKER
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:PARKER
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 DUNSTON AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35213-1601
Mailing Address - Country:US
Mailing Address - Phone:251-401-6686
Mailing Address - Fax:
Practice Address - Street 1:100 57TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35212-2541
Practice Address - Country:US
Practice Address - Phone:205-591-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL65331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice