Provider Demographics
NPI:1750401295
Name:GOBER, KELLY RAY (DMD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:RAY
Last Name:GOBER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RAVENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30178-1510
Mailing Address - Country:US
Mailing Address - Phone:770-606-0607
Mailing Address - Fax:
Practice Address - Street 1:440 ERNEST W BARRETT PKWY NW
Practice Address - Street 2:SUITE 29
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4918
Practice Address - Country:US
Practice Address - Phone:770-427-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0122911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice