Provider Demographics
NPI:1134513146
Name:KELLY, DANIEL (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:KELLY
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 1:2301 W SAMPLE RD STE 7B
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33073-3081
Mailing Address - Country:US
Mailing Address - Phone:305-624-2629
Mailing Address - Fax:
Practice Address - Street 1:2301 W SAMPLE RD STE 7B
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33073-3081
Practice Address - Country:US
Practice Address - Phone:305-624-2629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBK0936154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist