Provider Demographics
NPI:1598758591
Name:BARNES, KELLIE ELIZABETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:ELIZABETH
Last Name:BARNES
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 1:2646 E JOYCE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4435
Mailing Address - Country:US
Mailing Address - Phone:479-443-8009
Mailing Address - Fax:479-443-4450
Practice Address - Street 1:2646 E JOYCE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4435
Practice Address - Country:US
Practice Address - Phone:479-443-8009
Practice Address - Fax:479-443-4450
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5660122300000X
ARAR3678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR177181608Medicaid
AR1558695601OtherTYPE 2 NPI