Provider Demographics
NPI:1235210980
Name:KELLY, JOSEPH CRAIG (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:CRAIG
Last Name:KELLY
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 1:3675 HENDRICKS AVE.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-5360
Mailing Address - Country:US
Mailing Address - Phone:904-398-1549
Mailing Address - Fax:904-398-1551
Practice Address - Street 1:3675 HENDRICKS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5360
Practice Address - Country:US
Practice Address - Phone:904-398-1549
Practice Address - Fax:904-398-1551
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN60231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice