Provider Demographics
NPI:1982042081
Name:THIELE, KELLI DANIELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:DANIELLE
Last Name:THIELE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KELLI
Other - Middle Name:DANIELLE
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:205 E HARCOURT RD
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-7131
Mailing Address - Country:US
Mailing Address - Phone:260-665-5767
Mailing Address - Fax:
Practice Address - Street 1:205 E HARCOURT RD
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-7131
Practice Address - Country:US
Practice Address - Phone:260-665-5767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120111974A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist