Provider Demographics
NPI:1679515696
Name:MACK, KELLI C (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:C
Last Name:MACK
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 1:1615 TRUEMPER ST
Mailing Address - Street 2:
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5511
Mailing Address - Country:US
Mailing Address - Phone:210-539-7011
Mailing Address - Fax:
Practice Address - Street 1:1615 TRUEMPER ST
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5511
Practice Address - Country:US
Practice Address - Phone:210-539-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44021122300000X, 1223G0001X
TX219671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist