Provider Demographics
NPI:1740656966
Name:MARTIN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 OLD CHEROKEE RD
Mailing Address - Street 2:SUITE F, PMB 14
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9316
Mailing Address - Country:US
Mailing Address - Phone:803-808-2304
Mailing Address - Fax:
Practice Address - Street 1:100 OLD CHEROKEE RD
Practice Address - Street 2:SUITE F, PMB 14
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9316
Practice Address - Country:US
Practice Address - Phone:803-808-2304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2601124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist