Healthcare Provider Details

I. General information

NPI: 1245970839
Provider Name (Legal Business Name): KELLY GWEN BLISS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 MEDWAY RD STE 2&3
MILFORD MA
01757-2915
US

IV. Provider business mailing address

121 LINDEN ST
DOUGLAS MA
01516-2467
US

V. Phone/Fax

Practice location:
  • Phone: 781-325-1091
  • Fax:
Mailing address:
  • Phone: 508-404-6751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1859382
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: