Provider Demographics
NPI:1972759546
Name:KINGMA, KELLY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LEE
Last Name:KINGMA
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 1:2217 HARVEST CIR
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-3466
Mailing Address - Country:US
Mailing Address - Phone:319-530-3626
Mailing Address - Fax:
Practice Address - Street 1:3024 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-2793
Practice Address - Country:US
Practice Address - Phone:563-332-2447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08557122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist