Provider Demographics
NPI:1629419213
Name:MCKINNEY, KELLY LYNN (DMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 HIGHWAY 367 N STE 300
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-2499
Mailing Address - Country:US
Mailing Address - Phone:870-523-6575
Mailing Address - Fax:
Practice Address - Street 1:2308 HIGHWAY 367 N STE 300
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-2499
Practice Address - Country:US
Practice Address - Phone:870-523-6575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist