Provider Demographics
NPI:1588006068
Name:ZHAO, KELLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:ZHAO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 ELLA BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-4210
Mailing Address - Country:US
Mailing Address - Phone:832-410-1000
Mailing Address - Fax:832-553-1900
Practice Address - Street 1:4212 ELLA BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-4210
Practice Address - Country:US
Practice Address - Phone:832-410-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX292851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX339719210Medicaid