Healthcare Provider Details

I. General information

NPI: 1114441995
Provider Name (Legal Business Name): KELLY HUGHES, DMD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TOWN PARK BLVD STE 400
EVANS GA
30809-3471
US

IV. Provider business mailing address

400 TOWN PARK BLVD STE 400
EVANS GA
30809-3471
US

V. Phone/Fax

Practice location:
  • Phone: 706-288-1100
  • Fax: 706-288-1060
Mailing address:
  • Phone: 706-288-1100
  • Fax: 706-288-1060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN012769
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. KELLY HUGHES
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 706-399-8601