MEDICARE: KENITRA KELLY DMD

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	122300000X	Dentist	DN21192	FL

General Provider Information

NPI Number	:	1861872988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENITRA KELLY DMD

Provider Business Mailing Address
First Line	:	2943 TRAVERSE TRL
Second Line	:
City	:	THE VILLAGES
State	:	FL
Zip	:	32163-2017
Country	:	US
Telephone Number	:	352-877-2461
Fax Number	:

Provider Business Practice Location Address
First Line	:	2943 TRAVERSE TRL
Second Line	:
City	:	THE VILLAGES
State	:	FL
Zip	:	32163-2017
Country	:	US
Telephone Number	:	352-877-2461
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2015
Last Update Date	:	06/03/2015

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