Provider Demographics
NPI:1013282961
Name:KELLY, SHENIKA SHAREE
Entity Type:Individual
Prefix:
First Name:SHENIKA
Middle Name:SHAREE
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 GREENFIELD RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-7023
Mailing Address - Country:US
Mailing Address - Phone:601-672-6085
Mailing Address - Fax:844-270-0967
Practice Address - Street 1:514 E WOODROW WILSON AVE STE G
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:769-572-4425
Practice Address - Fax:844-270-0967
Is Sole Proprietor?:No
Enumeration Date:2012-03-11
Last Update Date:2018-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS3644-121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice