Healthcare Provider Details

I. General information

NPI: 1962549758
Provider Name (Legal Business Name): CHELITA KAYE KELLEY D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 ROZZELLES FERRY RD PEDIATRIC DENTISTRY
CHARLOTTE NC
28208-4228
US

IV. Provider business mailing address

1801 ROZZELLES FERRY RD
CHARLOTTE NC
28208-4228
US

V. Phone/Fax

Practice location:
  • Phone: 704-350-7305
  • Fax: 704-350-7304
Mailing address:
  • Phone: 704-350-7305
  • Fax: 704-350-7304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7311
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number7311
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: