Provider Demographics
NPI:1245308899
Name:MACK, KELLY ANNE (RD4)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANNE
Last Name:MACK
Suffix:
Gender:F
Credentials:RD4
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 GLACIER TRAIL
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172
Mailing Address - Country:US
Mailing Address - Phone:630-980-0992
Mailing Address - Fax:
Practice Address - Street 1:55 E LOOP RD
Practice Address - Street 2:GROVE DENTAL ASSOC SUITE 201
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187
Practice Address - Country:US
Practice Address - Phone:630-653-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist