Provider Demographics
NPI:1730475617
Name:BLANK, KELLI JEAN BRUNK (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:JEAN BRUNK
Last Name:BLANK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 W ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1234
Mailing Address - Country:US
Mailing Address - Phone:618-283-2929
Mailing Address - Fax:618-283-2113
Practice Address - Street 1:607 W ORCHARD ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1234
Practice Address - Country:US
Practice Address - Phone:618-283-2929
Practice Address - Fax:618-283-2113
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028666122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist