Provider Demographics
NPI:1164616488
Name:KELLY, EDWARD M JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:M
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:1726 W JARRETTSVILLE RD
Mailing Address - City:JARRETTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21804-1524
Mailing Address - Country:US
Mailing Address - Phone:410-557-7766
Mailing Address - Fax:410-557-6012
Practice Address - Street 1:1726 W JARRETTSVILLE RD
Practice Address - Street 2:
Practice Address - City:JARRETTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21804-1524
Practice Address - Country:US
Practice Address - Phone:410-557-7766
Practice Address - Fax:410-557-6012
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11585122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist