Provider Demographics
NPI:1225413461
Name:KELLY, JOSHUA CHAD (DMD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:CHAD
Last Name:KELLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 W 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEVERANCE
Mailing Address - State:CO
Mailing Address - Zip Code:80550-2949
Mailing Address - Country:US
Mailing Address - Phone:970-693-0080
Mailing Address - Fax:970-693-0081
Practice Address - Street 1:375 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:SEVERANCE
Practice Address - State:CO
Practice Address - Zip Code:80550
Practice Address - Country:US
Practice Address - Phone:970-693-0080
Practice Address - Fax:970-693-0081
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002025921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice