Provider Demographics
NPI:1154655629
Name:BREWER, KELLY ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:BREWER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 OAK AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1072
Mailing Address - Country:US
Mailing Address - Phone:530-758-3020
Mailing Address - Fax:530-758-3026
Practice Address - Street 1:1627 OAK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-1072
Practice Address - Country:US
Practice Address - Phone:530-758-3020
Practice Address - Fax:530-758-3026
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58852122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist