Provider Demographics
NPI:1629192380
Name:COUCH, KELLY P (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:COUCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7915 LAGUNA BLVD
Mailing Address - Street 2:SUITE #110
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7945
Mailing Address - Country:US
Mailing Address - Phone:916-683-2300
Mailing Address - Fax:916-683-2352
Practice Address - Street 1:7915 LAGUNA BLVD
Practice Address - Street 2:#110
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7945
Practice Address - Country:US
Practice Address - Phone:916-683-2300
Practice Address - Fax:916-683-2352
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA290291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice