Provider Demographics
NPI:1750943502
Name:JUSTICE, KELLEY MARIE (DMD)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:MARIE
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 CHINOOK CIR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-8233
Mailing Address - Country:US
Mailing Address - Phone:217-313-1071
Mailing Address - Fax:
Practice Address - Street 1:1466 TINY TOWN RD STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-8292
Practice Address - Country:US
Practice Address - Phone:931-548-0119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN110941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice