Provider Demographics
NPI:1306224142
Name:KELLY, KERRY LYN (DDS)
Entity Type:Individual
Prefix:MISS
First Name:KERRY
Middle Name:LYN
Last Name:KELLY
Suffix:
Gender:F
Credentials:DDS
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Mailing Address - Street 1:14 MAIDEN LN
Mailing Address - Street 2:PO BOX 423
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1208
Mailing Address - Country:US
Mailing Address - Phone:315-531-9102
Mailing Address - Fax:315-531-9103
Practice Address - Street 1:6692 MIDDLE RD
Practice Address - Street 2:SUITE 2100
Practice Address - City:SODUS
Practice Address - State:NY
Practice Address - Zip Code:14551-9602
Practice Address - Country:US
Practice Address - Phone:315-483-1199
Practice Address - Fax:315-483-2451
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2016-10-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY0588461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY058846OtherLICENSE