Provider Demographics
NPI:1699262493
Name:KELLY BLAIR D.D.S., PLLC
Entity type:Organization
Organization Name:KELLY BLAIR D.D.S., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-737-5155
Mailing Address - Street 1:6316 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5418
Mailing Address - Country:US
Mailing Address - Phone:817-737-5155
Mailing Address - Fax:817-737-4095
Practice Address - Street 1:6316 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5418
Practice Address - Country:US
Practice Address - Phone:817-737-5155
Practice Address - Fax:817-737-4095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies