Provider Demographics
NPI:1720169170
Name:KELLEY, KIMBERLY A (DDS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:KELLEY
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:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:KENDALIA
Mailing Address - State:TX
Mailing Address - Zip Code:78027-0458
Mailing Address - Country:US
Mailing Address - Phone:830-336-2830
Mailing Address - Fax:
Practice Address - Street 1:1103 HWY 3351 N
Practice Address - Street 2:
Practice Address - City:KENDALIA
Practice Address - State:TX
Practice Address - Zip Code:78027
Practice Address - Country:US
Practice Address - Phone:830-336-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX162011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice