Provider Demographics
NPI:1487718177
Name:VAUGHN, KELLY ANNE (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANNE
Last Name:VAUGHN
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 1:9020 HIGHWAY 92
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3753
Mailing Address - Country:US
Mailing Address - Phone:770-928-4511
Mailing Address - Fax:770-928-4310
Practice Address - Street 1:9020 HIGHWAY 92
Practice Address - Street 2:SUITE 120
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-3753
Practice Address - Country:US
Practice Address - Phone:770-928-4511
Practice Address - Fax:770-928-4310
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice