Provider Demographics
NPI:1467908814
Name:GRIFFITH, KELLY LAUREN (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LAUREN
Last Name:GRIFFITH
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LAUREN
Other - Last Name:VAN WAGENEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:151 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1056
Mailing Address - Country:US
Mailing Address - Phone:860-537-1444
Mailing Address - Fax:
Practice Address - Street 1:151 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1056
Practice Address - Country:US
Practice Address - Phone:860-537-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10574122300000X
NC151098122300000X
CT142451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist