Provider Demographics
NPI:1528192390
Name:WINCHESTER POVAR, KELLY M (RDH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:WINCHESTER POVAR
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:PROVAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDH
Mailing Address - Street 1:2487 S GILBERT RD STE 105
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-5802
Mailing Address - Country:US
Mailing Address - Phone:480-732-1888
Mailing Address - Fax:480-732-1890
Practice Address - Street 1:2487 S GILBERT RD STE 105
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-5802
Practice Address - Country:US
Practice Address - Phone:480-732-1888
Practice Address - Fax:480-732-1890
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5228124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist