Provider Demographics
NPI:1992816151
Name:MOTT, KELLY N (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:N
Last Name:MOTT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:PEARCY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1422 QUARRIER ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-3015
Mailing Address - Country:US
Mailing Address - Phone:304-343-3412
Mailing Address - Fax:304-343-5091
Practice Address - Street 1:1422 QUARRIER ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3015
Practice Address - Country:US
Practice Address - Phone:304-343-3412
Practice Address - Fax:304-343-5091
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136642000Medicaid