Provider Demographics
NPI:1447645684
Name:LAVIN, KELLEY DOHERTY (RDH)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:DOHERTY
Last Name:LAVIN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 STATE ROUTE 101
Mailing Address - Street 2:VILLAGE SHOPPES BEDFORD
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-5417
Mailing Address - Country:US
Mailing Address - Phone:603-472-5733
Mailing Address - Fax:
Practice Address - Street 1:174 STATE ROUTE 101
Practice Address - Street 2:VILLAGE SHOPPES BEDFORD
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-5417
Practice Address - Country:US
Practice Address - Phone:603-472-5733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-04
Last Update Date:2015-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH02125124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist