Provider Demographics
NPI:1245436997
Name:KELLY, KATHERINE ANNE (DDS, PHD,MS)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:KELLY
Suffix:
Gender:F
Credentials:DDS, PHD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1020 E MICHIGAN AVE
Mailing Address - Street 2:PRIVATE PRACTICE
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-1525
Mailing Address - Country:US
Mailing Address - Phone:734-429-7676
Mailing Address - Fax:734-470-6646
Practice Address - Street 1:1020 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1525
Practice Address - Country:US
Practice Address - Phone:734-429-7676
Practice Address - Fax:734-470-6646
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010178561223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics