Provider Demographics
NPI:1619289246
Name:SMITH-CASTRO, KELLIE DENIA (DMD)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:DENIA
Last Name:SMITH-CASTRO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:D
Other - Last Name:CASTRO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1860 DULUTH HWY STE 401
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5061
Mailing Address - Country:US
Mailing Address - Phone:782-269-0636
Mailing Address - Fax:678-226-9445
Practice Address - Street 1:1860 DULUTH HWY STE 401
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043
Practice Address - Country:US
Practice Address - Phone:678-226-9063
Practice Address - Fax:678-226-9445
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC89931223G0001X
GADN015357122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice