Provider Demographics
NPI:1144438060
Name:MCCLELLAN, KIAMESHA MICHALLE (DDS)
Entity type:Individual
Prefix:
First Name:KIAMESHA
Middle Name:MICHALLE
Last Name:MCCLELLAN
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 1:2200 MORRISS RD STE 150
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-3239
Mailing Address - Country:US
Mailing Address - Phone:972-539-4290
Mailing Address - Fax:975-355-1736
Practice Address - Street 1:2200 MORRISS RD STE 150
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-3239
Practice Address - Country:US
Practice Address - Phone:972-539-4290
Practice Address - Fax:975-355-1736
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX158841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice