Provider Demographics
NPI:1558772723
Name:GWENDOLYN KELLY DDS & ASSOC.
Entity Type:Organization
Organization Name:GWENDOLYN KELLY DDS & ASSOC.
Other - Org Name:GWENDOLYN KELLY DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-412-9291
Mailing Address - Street 1:6230 W MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6230 W MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3801
Practice Address - Country:US
Practice Address - Phone:310-412-9291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29936122300000X
CA454721223E0200X
CA200701223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty