Provider Demographics
NPI:1275837825
Name:KELLIHER, JEREMIAH JOSEPH JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:JOSEPH
Last Name:KELLIHER
Suffix:JR
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 1:6120 BRANDON AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2522
Mailing Address - Country:US
Mailing Address - Phone:703-451-5030
Mailing Address - Fax:
Practice Address - Street 1:6120 BRANDON AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2522
Practice Address - Country:US
Practice Address - Phone:703-451-5030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401006572122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist