Healthcare Provider Details

I. General information

NPI: 1376805804
Provider Name (Legal Business Name): KELLY ANN BROWN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 HOLLAND ST
ROCHESTER NY
14605-2131
US

IV. Provider business mailing address

404 BARKS RD
CALEDONIA NY
14423-9752
US

V. Phone/Fax

Practice location:
  • Phone: 585-423-5838
  • Fax:
Mailing address:
  • Phone: 585-519-8841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number023561-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: