Provider Demographics
NPI:1689890907
Name:GERARD, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GERARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 MATLOCK RD
Mailing Address - Street 2:STE 100
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-2917
Mailing Address - Country:US
Mailing Address - Phone:817-419-9700
Mailing Address - Fax:
Practice Address - Street 1:3330 MATLOCK RD
Practice Address - Street 2:STE 100
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2917
Practice Address - Country:US
Practice Address - Phone:817-419-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12885124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist