Provider Demographics
NPI:1801053509
Name:KELLY, CHRISTIAN H (DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:H
Last Name:KELLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 N MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:HUNTINGBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47542
Mailing Address - Country:US
Mailing Address - Phone:812-683-1112
Mailing Address - Fax:888-958-7816
Practice Address - Street 1:1690 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542
Practice Address - Country:US
Practice Address - Phone:812-683-1112
Practice Address - Fax:888-958-7816
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011133A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice