Provider Demographics
NPI:1396084034
Name:KELLY, CAROL (DENTAL HYGIENIST)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 W 38TH AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4300
Mailing Address - Country:US
Mailing Address - Phone:303-467-8888
Mailing Address - Fax:303-467-8801
Practice Address - Street 1:8550 W 38TH AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4300
Practice Address - Country:US
Practice Address - Phone:303-467-8888
Practice Address - Fax:303-467-8801
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904143124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12826740Medicaid