MEDICARE: KELLY BLAIR D.D.S., PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1699262493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY BLAIR D.D.S., PLLC

Provider Business Mailing Address
First Line	:	6316 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5418
Country	:	US
Telephone Number	:	817-737-5155
Fax Number	:	817-737-4095

Provider Business Practice Location Address
First Line	:	6316 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5418
Country	:	US
Telephone Number	:	817-737-5155
Fax Number	:	817-737-4095

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. KELLY BLAIR
Credential	:	DDS
Telephone Number	:	817-737-5155

Provider Enumeration Date	:	04/17/2018
Last Update Date	:	05/08/2018

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