Provider Demographics
NPI:1205325446
Name:ADAMS, KELLY JANE (RDH, LPN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JANE
Last Name:ADAMS
Suffix:
Gender:F
Credentials:RDH, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10943 HODGE CANYON DR
Mailing Address - Street 2:
Mailing Address - City:SALADO
Mailing Address - State:TX
Mailing Address - Zip Code:76571-6319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10943 HODGE CANYON DR
Practice Address - Street 2:
Practice Address - City:SALADO
Practice Address - State:TX
Practice Address - Zip Code:76571-6319
Practice Address - Country:US
Practice Address - Phone:740-525-1259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21009124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty