Provider Demographics
NPI:1033671466
Name:KELLEY, MEGHAN ABIGAIL
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:ABIGAIL
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 1:76 PEQUOT POINT RD
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-5114
Mailing Address - Country:US
Mailing Address - Phone:508-505-0718
Mailing Address - Fax:
Practice Address - Street 1:79 BROAD ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-2999
Practice Address - Country:US
Practice Address - Phone:413-420-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18583841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice