Provider Demographics
NPI:1215232244
Name:KELLY SKERRETT PC
Entity Type:Organization
Organization Name:KELLY SKERRETT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.D.S.
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SKERRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-901-1440
Mailing Address - Street 1:520 W HURON ST
Mailing Address - Street 2:APT 402
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 W HURON ST
Practice Address - Street 2:APT 402
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3432
Practice Address - Country:US
Practice Address - Phone:716-901-1440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-23
Last Update Date:2011-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0283031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty