Provider Demographics
NPI:1902979628
Name:BLAIR, KELLY G (DDS)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:G
Last Name:BLAIR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:BLAIR
Other - Last Name:CREASY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:6316 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5418
Mailing Address - Country:US
Mailing Address - Phone:817-737-5155
Mailing Address - Fax:817-737-4095
Practice Address - Street 1:6316 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5418
Practice Address - Country:US
Practice Address - Phone:817-737-5155
Practice Address - Fax:817-737-4095
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000103451223G0001X
TX275481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice