Provider Demographics
NPI:1275994964
Name:JAMES S. KELLY D.M.D. A PROFESIONAL CORP
Entity Type:Organization
Organization Name:JAMES S. KELLY D.M.D. A PROFESIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:650-380-2616
Mailing Address - Street 1:23450 RAVENSBURY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-6517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23450 RAVENSBURY AVE
Practice Address - Street 2:
Practice Address - City:LOS ALTOS HILLS
Practice Address - State:CA
Practice Address - Zip Code:94024-6517
Practice Address - Country:US
Practice Address - Phone:650-380-2616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 30395261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center