Provider Demographics
NPI:1962549758
Name:KELLEY, CHELITA KAYE (DDS)
Entity type:Individual
Prefix:DR
First Name:CHELITA
Middle Name:KAYE
Last Name:KELLEY
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 1:1801 ROZZELLES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-4228
Mailing Address - Country:US
Mailing Address - Phone:704-350-7305
Mailing Address - Fax:704-350-7304
Practice Address - Street 1:1801 ROZZELLES FERRY RD
Practice Address - Street 2:PEDIATRIC DENTISTRY
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-4228
Practice Address - Country:US
Practice Address - Phone:704-350-7305
Practice Address - Fax:704-350-7304
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73111223P0221X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905875Medicaid