Provider Demographics
NPI:1285702332
Name:HUGHES, KELLY WALLACE (DMD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:WALLACE
Last Name:HUGHES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1243 AUGUSTA WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1807
Mailing Address - Country:US
Mailing Address - Phone:706-855-8989
Mailing Address - Fax:706-855-0321
Practice Address - Street 1:1243 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1807
Practice Address - Country:US
Practice Address - Phone:706-855-8989
Practice Address - Fax:706-855-0321
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0127691223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100202OtherAVESIS MEDICAID
GA374703901BMedicaid
GA374703901BMedicaid