Provider Demographics
NPI:1255688933
Name:KANEMARU-TAKEUCHI, KELLI K (DDS)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:K
Last Name:KANEMARU-TAKEUCHI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 W LOWDER ST
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2664
Mailing Address - Country:US
Mailing Address - Phone:904-259-6291
Mailing Address - Fax:904-259-1950
Practice Address - Street 1:480 W LOWDER ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2664
Practice Address - Country:US
Practice Address - Phone:904-259-6291
Practice Address - Fax:904-259-1950
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHAD491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice