Provider Demographics
NPI:1790222479
Name:WARD, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1173 ANGEL HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-1530
Mailing Address - Country:US
Mailing Address - Phone:707-407-8071
Mailing Address - Fax:
Practice Address - Street 1:101 WEST COAST ROAD SUITE A
Practice Address - Street 2:
Practice Address - City:REDWAY
Practice Address - State:CA
Practice Address - Zip Code:95560
Practice Address - Country:US
Practice Address - Phone:707-923-4313
Practice Address - Fax:707-923-2590
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29096124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist