Healthcare Provider Details

I. General information

NPI: 1770210932
Provider Name (Legal Business Name): KELLY JEAN KITTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2022
Last Update Date: 08/06/2022
Certification Date: 08/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 DUNDEE DR APT 2
MINOT AFB ND
58704-1491
US

IV. Provider business mailing address

33 DUNDEE DR APT 2
MINOT AFB ND
58704-1491
US

V. Phone/Fax

Practice location:
  • Phone: 740-357-8235
  • Fax:
Mailing address:
  • Phone: 740-357-8235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: