Provider Demographics
NPI:1003212937
Name:KELLY PALCHIK DMD, PC
Entity Type:Organization
Organization Name:KELLY PALCHIK DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PALCHIK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-263-2853
Mailing Address - Street 1:84 MAIN ST S
Mailing Address - Street 2:PO BOX 407
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-3403
Mailing Address - Country:US
Mailing Address - Phone:203-263-2853
Mailing Address - Fax:203-263-2859
Practice Address - Street 1:84 MAIN ST S
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3403
Practice Address - Country:US
Practice Address - Phone:203-263-2853
Practice Address - Fax:203-263-2859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010935122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty