Provider Demographics
NPI:1518532134
Name:DAVIS, KELLY DIANE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 HAMAKUA PL
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-3924
Mailing Address - Country:US
Mailing Address - Phone:856-419-8707
Mailing Address - Fax:
Practice Address - Street 1:970 N KALAHEO AVE STE A101
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-1868
Practice Address - Country:US
Practice Address - Phone:808-254-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJHI-01081900124Q00000X
HIDH-2142124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist