Provider Demographics
NPI:1700057478
Name:KELLY VAUGHN DDS PC
Entity Type:Organization
Organization Name:KELLY VAUGHN DDS PC
Other - Org Name:FIRST CHOICE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FALVAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-581-0063
Mailing Address - Street 1:1610 RIDENOUR BLVD NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4484
Mailing Address - Country:US
Mailing Address - Phone:678-581-0063
Mailing Address - Fax:678-581-0246
Practice Address - Street 1:1610 RIDENOUR BLVD NW
Practice Address - Street 2:SUITE 103
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4484
Practice Address - Country:US
Practice Address - Phone:678-581-0063
Practice Address - Fax:678-581-0246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012608122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty