Provider Demographics
NPI:1750826590
Name:LOVE, KELLY (RDH)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:LOVE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:ANGUISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:2804 REMINGTON GREEN CIR STE 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-1550
Mailing Address - Country:US
Mailing Address - Phone:850-385-4494
Mailing Address - Fax:850-298-6054
Practice Address - Street 1:1850 S BYRON BUTLER PKWY
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32348
Practice Address - Country:US
Practice Address - Phone:850-223-2578
Practice Address - Fax:850-223-3047
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25088124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019726200Medicaid