Provider Demographics
NPI:1457799082
Name:GUEDRY, KELLY ELIZABETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ELIZABETH
Last Name:GUEDRY
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 1:3526 BON SEJOUR AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70820-5061
Mailing Address - Country:US
Mailing Address - Phone:985-513-0681
Mailing Address - Fax:
Practice Address - Street 1:11990 JACKSON ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722-3210
Practice Address - Country:US
Practice Address - Phone:225-683-5292
Practice Address - Fax:225-683-1310
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA63491223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1863491Medicaid