Provider Demographics
NPI:1306193396
Name:LEFTWICH, KELLY THOMPSON (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:THOMPSON
Last Name:LEFTWICH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LAUREN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15435 GLENEAGLE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-2542
Mailing Address - Country:US
Mailing Address - Phone:719-481-6788
Mailing Address - Fax:
Practice Address - Street 1:15435 GLENEAGLE DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-2542
Practice Address - Country:US
Practice Address - Phone:719-481-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413676122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist