Provider Demographics
NPI:1992189674
Name:KELLY, TAWAPHAN W (DDS)
Entity Type:Individual
Prefix:
First Name:TAWAPHAN
Middle Name:W
Last Name:KELLY
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 1:3773 PATRIOT DR APT 101
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-1843
Mailing Address - Country:US
Mailing Address - Phone:402-670-8963
Mailing Address - Fax:
Practice Address - Street 1:4754 S 14TH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-4733
Practice Address - Country:US
Practice Address - Phone:325-480-1524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7214122300000X
TX327761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist