MEDICARE: DR. KELLY BLENKHORN DEMAREST DMD

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	1223G0001X	General Practice Dentistry	18955	MA

General Provider Information

NPI Number	:	1881759561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY BLENKHORN DEMAREST DMD

Provider Business Mailing Address
First Line	:	31 CROWELL RD
Second Line	:
City	:	SAGAMORE BEACH
State	:	MA
Zip	:	02562-2610
Country	:	US
Telephone Number	:	508-888-1256
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 CEDAR ST
Second Line	:
City	:	HYANNIS
State	:	MA
Zip	:	02601-3009
Country	:	US
Telephone Number	:	508-790-7801
Fax Number	:	508-775-5608

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

Provider Enumeration Date	:	12/24/2006
Last Update Date	:	07/08/2007

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