Provider Demographics
NPI:1932281177
Name:SMUDDE, KELLY KATHELEEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:KATHELEEN
Last Name:SMUDDE
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 1:25880 TOURNAMENT RD STE 103
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-2378
Mailing Address - Country:US
Mailing Address - Phone:661-259-4474
Mailing Address - Fax:661-259-1371
Practice Address - Street 1:25880 TOURNAMENT RD STE 103
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-2378
Practice Address - Country:US
Practice Address - Phone:661-259-4474
Practice Address - Fax:661-259-1371
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA453231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice