Provider Demographics
NPI:1508068347
Name:THOMAS, KELLY R (DMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12575 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-0517
Mailing Address - Country:US
Mailing Address - Phone:503-644-7697
Mailing Address - Fax:
Practice Address - Street 1:12575 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-0517
Practice Address - Country:US
Practice Address - Phone:503-644-7697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6393122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist