Provider Demographics
NPI:1689003105
Name:HALE, KELLY (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:HALE
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:PO BOX 1526
Mailing Address - Street 2:
Mailing Address - City:BUDA
Mailing Address - State:TX
Mailing Address - Zip Code:78610-1526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-3184
Practice Address - Country:US
Practice Address - Phone:512-426-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX157941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice