Provider Demographics
NPI:1063433654
Name:TRUONG, KELLY M (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:TRUONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:55 CROSSPOINT PARKWAY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GETZVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14068-1615
Mailing Address - Country:US
Mailing Address - Phone:716-639-5900
Mailing Address - Fax:716-639-5901
Practice Address - Street 1:55 CROSSPOINT PARKWAY
Practice Address - Street 2:SUITE 130
Practice Address - City:GETZVILLE
Practice Address - State:NY
Practice Address - Zip Code:14068-1615
Practice Address - Country:US
Practice Address - Phone:716-639-5900
Practice Address - Fax:716-639-5901
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051944122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02647074Medicaid