Provider Demographics
NPI:1508835984
Name:GALLAHER, KELL DARREN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELL
Middle Name:DARREN
Last Name:GALLAHER
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 1:1026 THOMPSON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-1704
Mailing Address - Country:US
Mailing Address - Phone:770-297-0401
Mailing Address - Fax:770-297-8477
Practice Address - Street 1:1026 THOMPSON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-1704
Practice Address - Country:US
Practice Address - Phone:770-297-0401
Practice Address - Fax:770-297-8477
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0118391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00883099BMedicaid