Provider Demographics
NPI:1033434659
Name:CROMPTON PARK ORAL SURGERY AND IMPLANT ASSOCIATES, LLC
Entity Type:Organization
Organization Name:CROMPTON PARK ORAL SURGERY AND IMPLANT ASSOCIATES, LLC
Other - Org Name:W. DAVID KELLY, DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:W DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-799-2550
Mailing Address - Street 1:59 QUINSIGAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-1867
Mailing Address - Country:US
Mailing Address - Phone:508-799-2550
Mailing Address - Fax:508-756-2923
Practice Address - Street 1:59 QUINSIGAMOND AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-1867
Practice Address - Country:US
Practice Address - Phone:508-799-2550
Practice Address - Fax:508-756-2923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-07
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA122221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110009711AMedicaid
MAT57152Medicare UPIN