Provider Demographics
NPI:1689849598
Name:KELLY E. CARLEN, DDS PLLC
Entity Type:Organization
Organization Name:KELLY E. CARLEN, DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:CARLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-461-1060
Mailing Address - Street 1:2811 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8482
Mailing Address - Country:US
Mailing Address - Phone:208-461-1060
Mailing Address - Fax:208-465-6303
Practice Address - Street 1:2811 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8482
Practice Address - Country:US
Practice Address - Phone:208-461-1060
Practice Address - Fax:208-465-6303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3271261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8061407Medicaid