Provider Demographics
NPI:1881769446
Name:KELLEY, ANDREA JILL
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:JILL
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2503
Mailing Address - Country:US
Mailing Address - Phone:850-837-7448
Mailing Address - Fax:850-837-2042
Practice Address - Street 1:1545 POWERS FERRY RD SE
Practice Address - Street 2:SUITE B
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-9412
Practice Address - Country:US
Practice Address - Phone:770-980-9404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0133481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice