Provider Demographics
NPI:1588893168
Name:MOORE, KELLY SUZANN (DMD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:SUZANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 DOVE RUN RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-3584
Mailing Address - Country:US
Mailing Address - Phone:859-266-2149
Mailing Address - Fax:
Practice Address - Street 1:1081 DOVE RUN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-3584
Practice Address - Country:US
Practice Address - Phone:859-266-2149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-05
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY87611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice