Provider Demographics
NPI:1508341694
Name:KELL, TOMMIE JANAE (EPDH)
Entity Type:Individual
Prefix:MRS
First Name:TOMMIE
Middle Name:JANAE
Last Name:KELL
Suffix:
Gender:F
Credentials:EPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 816
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-0816
Mailing Address - Country:US
Mailing Address - Phone:541-817-6453
Mailing Address - Fax:
Practice Address - Street 1:235 W MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9278
Practice Address - Country:US
Practice Address - Phone:541-817-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH6066124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist