Provider Demographics
NPI:1063035715
Name:MICHAELS, KELLIE ANN (DMD)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:MICHAELS
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 1:161 CLINT DR STE 300
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-7794
Mailing Address - Country:US
Mailing Address - Phone:614-866-3636
Mailing Address - Fax:
Practice Address - Street 1:161 CLINT DR STE 300
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-7794
Practice Address - Country:US
Practice Address - Phone:614-866-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0275651223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics