Provider Demographics
NPI:1871087163
Name:QUOLAS, KELLEY JESSICA (RDH)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:JESSICA
Last Name:QUOLAS
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 1:5150 N 16TH ST STE B147
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3916
Mailing Address - Country:US
Mailing Address - Phone:602-699-5983
Mailing Address - Fax:
Practice Address - Street 1:5150 N 16TH ST STE B147
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3916
Practice Address - Country:US
Practice Address - Phone:602-699-5983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH06628174400000X, 125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No125J00000XDental ProvidersDental Therapist