Provider Demographics
NPI:1649010091
Name:KELLEY, JACQUELINE (DMD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:DARLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1612 HIGBEE MILL ROAD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3141 BEAUMONT CENTRE CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1960
Practice Address - Country:US
Practice Address - Phone:859-223-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-31
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11130122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist