Healthcare Provider Details

I. General information

NPI: 1922679943
Provider Name (Legal Business Name): KELLY GANZEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8955 WOOD ROAD BUILDING 1
BETHESDA MD
20899
US

IV. Provider business mailing address

8015 OLD GEORGETOWN RD APT 737
BETHESDA MD
20814-2590
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-0064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1922679943
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: