Provider Demographics
NPI:1992206593
Name:DR. KELLI DMD, PA
Entity Type:Organization
Organization Name:DR. KELLI DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:EBERHARDT
Authorized Official - Last Name:SALOMON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-304-1900
Mailing Address - Street 1:1729 HERITAGE TRL # 904
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34112-7591
Mailing Address - Country:US
Mailing Address - Phone:239-304-1900
Mailing Address - Fax:239-304-1917
Practice Address - Street 1:1729 HERITAGE TRL # 904
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-7591
Practice Address - Country:US
Practice Address - Phone:239-304-1900
Practice Address - Fax:239-304-1917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22050261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental