Provider Demographics
NPI:1740452465
Name:DIANE C KELLY DMD, PC
Entity type:Organization
Organization Name:DIANE C KELLY DMD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER - AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-714-7011
Mailing Address - Street 1:655 JESSE JEWELL PKWY SE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501
Mailing Address - Country:US
Mailing Address - Phone:770-539-9110
Mailing Address - Fax:678-714-8388
Practice Address - Street 1:655 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-539-9110
Practice Address - Fax:678-714-8388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO120821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA186794814AMedicaid
GA191450941AMedicaid
GA390489607JMedicaid
GA000046582YMedicaid
GA919057925BMedicaid
GA514725717BMedicaid
GA000851727BMedicaid
GA609963109EMedicaid
GA218323780AMedicaid
GA609963109LMedicaid