Provider Demographics
NPI:1265630404
Name:KELLEHER, KEVIN ERICK (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ERICK
Last Name:KELLEHER
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 1:2412 COLONY CROSSING PL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4281
Mailing Address - Country:US
Mailing Address - Phone:804-739-6673
Mailing Address - Fax:
Practice Address - Street 1:2412 COLONY CROSSING PL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4281
Practice Address - Country:US
Practice Address - Phone:804-739-6673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014118841223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics