Provider Demographics
NPI:1285739193
Name:WHITE, KELLY K (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:K
Last Name:WHITE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W COLFAX AVE STE G
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-2071
Mailing Address - Country:US
Mailing Address - Phone:303-573-5533
Mailing Address - Fax:303-573-5539
Practice Address - Street 1:1050 W COLFAX AVE STE G
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-2071
Practice Address - Country:US
Practice Address - Phone:303-573-5533
Practice Address - Fax:303-573-5539
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1047521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840947326OtherEMPLOYER IDENTIFICATION #
CO600625OtherBLUE CROSS BLUE SHIELD
CO0006994162OtherUNITED CONCORDIA