Provider Demographics
NPI:1750861126
Name:LIGON, KELLY BICKLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:BICKLE
Last Name:LIGON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:BICKLE
Other - Last Name:STODDARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:PSC 475 BOX 1
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350-1200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 475 BX 1
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96350-9998
Practice Address - Country:US
Practice Address - Phone:315-243-7144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9188122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist