Healthcare Provider Details

I. General information

NPI: 1871158279
Provider Name (Legal Business Name): KELLI GUMM RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 CHAPIN ST
SOUTH BEND IN
46601-2541
US

IV. Provider business mailing address

32252 CHICAGO TRL
NEW CARLISLE IN
46552-8101
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-8220
  • Fax:
Mailing address:
  • Phone: 574-292-1267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number13004627A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: