Provider Demographics
NPI:1023781101
Name:KELLY, OLIVIA BREONNA (DDS)
Entity type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:BREONNA
Last Name:KELLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:BREONNA
Other - Last Name:BRITTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3113 ROSS ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79103-2700
Mailing Address - Country:US
Mailing Address - Phone:806-374-7341
Mailing Address - Fax:
Practice Address - Street 1:3113 ROSS ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79103-2700
Practice Address - Country:US
Practice Address - Phone:806-374-7341
Practice Address - Fax:806-322-0533
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX376311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice