Provider Demographics
NPI:1992008213
Name:POTTORF, KELLY G (HYGIENST)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:G
Last Name:POTTORF
Suffix:
Gender:F
Credentials:HYGIENST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 BIDDLE
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63107
Mailing Address - Country:US
Mailing Address - Phone:314-898-1717
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:1717 BIDDLE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-3454
Practice Address - Country:US
Practice Address - Phone:314-898-1717
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009007073124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2009007073Medicaid