Healthcare Provider Details

I. General information

NPI: 1265515399
Provider Name (Legal Business Name): KELLEY SUZANNE LYBRAND D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 WELLNESS BLVD
MONROE NC
28110-7774
US

IV. Provider business mailing address

1851 WELLNESS BLVD
MONROE NC
28110-7774
US

V. Phone/Fax

Practice location:
  • Phone: 704-291-7333
  • Fax: 704-292-1203
Mailing address:
  • Phone: 704-291-7333
  • Fax: 704-292-1203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDID19.ID
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7629
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: