Provider Demographics
NPI:1669147302
Name:WALKER, KELLY (DMD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:WALKER
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 1:41 MAYFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2808
Mailing Address - Country:US
Mailing Address - Phone:630-338-6439
Mailing Address - Fax:
Practice Address - Street 1:101 FULTON ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:IL
Practice Address - Zip Code:60481-1694
Practice Address - Country:US
Practice Address - Phone:815-476-6755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2022-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD115101223G0001X
IL0190337761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice