Provider Demographics
NPI:1447259262
Name:MINGUS, KELLEY RAY (DMD)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:RAY
Last Name:MINGUS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 SCALEHOUSE LOOP STE 101
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1241
Mailing Address - Country:US
Mailing Address - Phone:541-382-6565
Mailing Address - Fax:541-382-6776
Practice Address - Street 1:225 SCALEHOUSE LOOP STE 101
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1241
Practice Address - Country:US
Practice Address - Phone:541-382-6565
Practice Address - Fax:541-382-6776
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7191122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist