Provider Demographics
NPI:1154473106
Name:KELLEY, DAVID GENE (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GENE
Last Name:KELLEY
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 1:7500 80TH ST S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-3008
Mailing Address - Country:US
Mailing Address - Phone:651-459-3039
Mailing Address - Fax:651-459-9874
Practice Address - Street 1:7500 80TH ST S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-3008
Practice Address - Country:US
Practice Address - Phone:651-459-3039
Practice Address - Fax:651-459-9874
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist