Provider Demographics
NPI:1851431522
Name:KELLY, DIANE COLLETTE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:COLLETTE
Last Name:KELLY
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 1:2119 HAMILTON CREEK PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-3293
Mailing Address - Country:US
Mailing Address - Phone:678-714-7011
Mailing Address - Fax:678-714-8388
Practice Address - Street 1:2119 HAMILTON CREEK PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-3293
Practice Address - Country:US
Practice Address - Phone:678-714-7011
Practice Address - Fax:678-714-8388
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0120821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN012082OtherDENTAL LICENSE NUMBER