Provider Demographics
NPI:1457612228
Name:ACKLEY, KELLY NEDIMYER (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:NEDIMYER
Last Name:ACKLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 WESTSHORE DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-3042
Mailing Address - Country:US
Mailing Address - Phone:305-731-3267
Mailing Address - Fax:352-666-1148
Practice Address - Street 1:1530 PINEHURST DR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-4555
Practice Address - Country:US
Practice Address - Phone:352-683-7668
Practice Address - Fax:352-666-1148
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN196891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice