Provider Demographics
NPI:1821741851
Name:LE, KELLY NGUYEN (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NGUYEN
Last Name:LE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 EL CENTRO RD APT 938
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-2670
Mailing Address - Country:US
Mailing Address - Phone:503-887-4483
Mailing Address - Fax:
Practice Address - Street 1:3101 184TH ST SW STE 101
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-4851
Practice Address - Country:US
Practice Address - Phone:425-341-1653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-06-27
Deactivation Date:2022-05-25
Deactivation Code:
Reactivation Date:2022-06-27
Provider Licenses
StateLicense IDTaxonomies
390200000X
WA61250996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program