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General NPI Number Information
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NPI Number | 1205650264
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Entity Type | Organization
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Legal Business Name | KELLY HARRELSON DDS, PLLC
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Dates
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Enumeration Date | 11/14/2024
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Last Update Date | 11/14/2024
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Provider Practice Location Address
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Address Line | 1405 CANNON PKWY
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City | ROANOKE
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State | TX
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Zip | 76262-3620
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Country | US
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Telephone | 817-430-1212
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Fax | 817-491-0154
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Provider Business Mailing Address
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Address Line | 1405 CANNON PKWY
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City | ROANOKE
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State | TX
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Zip | 76262-3620
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Country | US
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Telephone | 817-430-1212
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Fax | 817-491-0154
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. KELLY HARRELSON
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Credential | DDS
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Telephone | 918-413-2774
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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