MEDICARE: KELLI DIANE CREEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	37335	TX

General Provider Information

NPI Number	:	1164092680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI DIANE CREEL

Provider Business Mailing Address
First Line	:	11138 HUEBNER OAKS APT 403
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1279
Country	:	US
Telephone Number	:	409-673-0156
Fax Number	:

Provider Business Practice Location Address
First Line	:	11831 CULEBRA RD STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-4578
Country	:	US
Telephone Number	:	210-625-5353
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2021
Last Update Date	:	06/28/2021

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Directions to “ KELLI DIANE CREEL ” Practice Location

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