Provider Demographics
NPI:1467908814
Name:VAN WAGENEN, KELLY LAUREN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LAUREN
Last Name:VAN WAGENEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LAUREN
Other - Last Name:GRIFFITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:10A YORKSHIRE ST STE 110
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-2718
Mailing Address - Country:US
Mailing Address - Phone:828-274-1616
Mailing Address - Fax:
Practice Address - Street 1:10A YORKSHIRE ST STE 110
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2718
Practice Address - Country:US
Practice Address - Phone:828-274-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC151098122300000X
NC10574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist