Provider Demographics
NPI:1780645002
Name:SOARES, KELLY (DMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SOARES
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 1:19 TACOMA ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3516
Mailing Address - Country:US
Mailing Address - Phone:508-852-1805
Mailing Address - Fax:508-853-8593
Practice Address - Street 1:30 SAINT JAMES AVE
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-2453
Practice Address - Country:US
Practice Address - Phone:413-592-2177
Practice Address - Fax:413-592-3278
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA197431223G0001X
MADN18579811223G0001X
MADN19743122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301071Medicaid