Healthcare Provider Details

I. General information

NPI: 1154988483
Provider Name (Legal Business Name): KELLY JEAN O'BRIEN CDA, RDH, MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY JEAN DODGE

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NHTI-CONCORD'S COMMUNITY COLLEGE 31 COLLEGE DRIVE
CONCORD NH
03301
US

IV. Provider business mailing address

NHTI-CONCORD'S COMMUNITY COLLEGE 31 COLLEGE DRIVE
CONCORD NH
03301
US

V. Phone/Fax

Practice location:
  • Phone: 603-271-6484
  • Fax:
Mailing address:
  • Phone: 603-271-6484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number02411
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: