Provider Demographics
NPI:1144339300
Name:PRIVETT, KELLY L (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:PRIVETT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-3020
Mailing Address - Country:US
Mailing Address - Phone:937-746-0539
Mailing Address - Fax:937-746-0530
Practice Address - Street 1:760 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-3020
Practice Address - Country:US
Practice Address - Phone:937-746-0539
Practice Address - Fax:937-746-0530
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-02238221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice