Provider Demographics
NPI:1780702472
Name:MACK, KELLY WADE (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:WADE
Last Name:MACK
Suffix:
Gender:M
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 HORSESHOE LN
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5648
Mailing Address - Country:US
Mailing Address - Phone:903-753-3673
Mailing Address - Fax:903-753-2637
Practice Address - Street 1:2200 HORSESHOE LN
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5648
Practice Address - Country:US
Practice Address - Phone:903-753-3673
Practice Address - Fax:903-753-2637
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice