Provider Demographics
NPI:1154446516
Name:KELLERT, MITCHELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:KELLERT
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 1:515 MADISON AVE
Mailing Address - Street 2:SUITE 715
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-5403
Mailing Address - Country:US
Mailing Address - Phone:212-355-4444
Mailing Address - Fax:212-355-4444
Practice Address - Street 1:515 MADISON AVE
Practice Address - Street 2:SUITE 715
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-5403
Practice Address - Country:US
Practice Address - Phone:212-355-4444
Practice Address - Fax:212-355-4444
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0327951223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics