Provider Demographics
NPI:1952663460
Name:KELLY, TRENT MERRILL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRENT
Middle Name:MERRILL
Last Name:KELLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3041
Mailing Address - Country:US
Mailing Address - Phone:208-999-4746
Mailing Address - Fax:
Practice Address - Street 1:1991 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3041
Practice Address - Country:US
Practice Address - Phone:208-999-4746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30023683122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist