Provider Demographics
NPI:1710991492
Name:KELLUM, DANIEL H (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:H
Last Name:KELLUM
Suffix:
Gender:M
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:PO BOX 1486
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38802-1486
Mailing Address - Country:US
Mailing Address - Phone:662-842-5080
Mailing Address - Fax:662-842-5896
Practice Address - Street 1:505 ROBINS ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-3715
Practice Address - Country:US
Practice Address - Phone:662-842-5080
Practice Address - Fax:662-842-5896
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1782-771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice