Provider Demographics
NPI:1770754426
Name:KELLY A. VAUGHN
Entity type:Organization
Organization Name:KELLY A. VAUGHN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FALVAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-928-4511
Mailing Address - Street 1:9020 HIGHWAY 92
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3753
Mailing Address - Country:US
Mailing Address - Phone:770-928-4511
Mailing Address - Fax:770-928-4310
Practice Address - Street 1:9020 HIGHWAY 92
Practice Address - Street 2:SUITE 120
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-3753
Practice Address - Country:US
Practice Address - Phone:770-928-4511
Practice Address - Fax:770-928-4310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA211792479NMedicaid