Provider Demographics
NPI:1497323117
Name:SMITH, KELLI SIMONE (DMD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:SIMONE
Last Name:SMITH
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 1:1630 MARKET CENTER BLVD FL 1
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8407
Mailing Address - Country:US
Mailing Address - Phone:636-300-4380
Mailing Address - Fax:636-300-0073
Practice Address - Street 1:1630 MARKET CENTER BLVD FL 1
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8407
Practice Address - Country:US
Practice Address - Phone:636-300-4380
Practice Address - Fax:636-300-0073
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210225561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice