Healthcare Provider Details

I. General information

NPI: 1730650870
Provider Name (Legal Business Name): KELLYE WATKINS WILSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S. CHARLES SEIVERS BLVD
CLINTON TN
37716
US

IV. Provider business mailing address

2750 DUTCH VALLEY RD
CLINTON TN
37716-5406
US

V. Phone/Fax

Practice location:
  • Phone: 865-457-1496
  • Fax:
Mailing address:
  • Phone: 865-254-4563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH00002692
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: