Provider Demographics
NPI:1104918945
Name:CHRISCO, KELLY J (DMD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:J
Last Name:CHRISCO
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 1:4384 CLEARWATER WAY STE 150
Mailing Address - Street 2:150
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515
Mailing Address - Country:US
Mailing Address - Phone:859-317-6810
Mailing Address - Fax:
Practice Address - Street 1:4384 CLEARWATER WAY STE 150
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515
Practice Address - Country:US
Practice Address - Phone:859-317-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY82381223D0001X, 1223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100006880Medicaid