Provider Demographics
NPI:1417287244
Name:CARBONE, KELLY (LD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CARBONE
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 FOREST AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3357
Mailing Address - Country:US
Mailing Address - Phone:207-774-7645
Mailing Address - Fax:207-828-5298
Practice Address - Street 1:980 FOREST AVE STE 104
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3357
Practice Address - Country:US
Practice Address - Phone:207-774-7645
Practice Address - Fax:207-828-5298
Is Sole Proprietor?:No
Enumeration Date:2009-12-29
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME5024122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist