Provider Demographics
NPI:1598494353
Name:CHICK, KELLY MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:CHICK
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 1:3031 CEDARBROOK RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-3406
Mailing Address - Country:US
Mailing Address - Phone:734-717-4765
Mailing Address - Fax:
Practice Address - Street 1:3250 PLYMOUTH RD STE 104
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2555
Practice Address - Country:US
Practice Address - Phone:734-717-4765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016013391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty