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General NPI Number Information
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NPI Number | 1457479818
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Entity Type | Individual
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Provider Name | KELLY ANN UNDERWOOD DMD
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Gender | Female
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 10/23/2013
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Provider Practice Location Address
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Address Line | 130 EVERGREEN RD SUITE 100
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City | LOUISVILLE
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State | KY
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Zip | 40243-1489
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Country | US
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Telephone | 502-410-1710
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Fax | 502-245-5021
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Provider Business Mailing Address
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Address Line | 130 EVERGREEN RD SUITE 100
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City | LOUISVILLE
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State | KY
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Zip | 40243-1489
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Country | US
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Telephone | 502-410-1710
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Fax | 502-245-5021
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 8450
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8450
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License Number State | KY
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