Provider Demographics
NPI:1730650870
Name:WILSON, KELLYE WATKINS (RDH)
Entity Type:Individual
Prefix:
First Name:KELLYE
Middle Name:WATKINS
Last Name:WILSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 DUTCH VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-5406
Mailing Address - Country:US
Mailing Address - Phone:865-254-4563
Mailing Address - Fax:
Practice Address - Street 1:420 S. CHARLES SEIVERS BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716
Practice Address - Country:US
Practice Address - Phone:865-457-1496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDH00002692124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist