Provider Demographics
NPI:1629577721
Name:KELLY, TINA MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4314
Mailing Address - Country:US
Mailing Address - Phone:989-755-0991
Mailing Address - Fax:989-755-0001
Practice Address - Street 1:427 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4314
Practice Address - Country:US
Practice Address - Phone:989-755-0991
Practice Address - Fax:989-755-0001
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902015161124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist