Provider Demographics
NPI:1245215920
Name:KELLY, MICHELLE J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:J
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:36032 RAVINIA PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-6714
Mailing Address - Country:US
Mailing Address - Phone:414-975-7190
Mailing Address - Fax:262-646-4181
Practice Address - Street 1:11 CROSSROADS CT
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-2035
Practice Address - Country:US
Practice Address - Phone:262-646-4188
Practice Address - Fax:262-646-4181
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5721-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice