Provider Demographics
NPI:1760582480
Name:WEST, KELLY NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:NICOLE
Last Name:WEST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1245 CHEYENNE AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024
Mailing Address - Country:US
Mailing Address - Phone:262-377-2668
Mailing Address - Fax:262-377-2680
Practice Address - Street 1:1245 CHEYENNE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024
Practice Address - Country:US
Practice Address - Phone:262-377-2668
Practice Address - Fax:262-377-2680
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018424122300000X
WI6129151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist