Provider Demographics
NPI:1326041385
Name:KELLY, W DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:W
Middle Name:DAVID
Last Name:KELLY
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 1:59 QUINSIGAMOND AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-1867
Mailing Address - Country:US
Mailing Address - Phone:508-799-2550
Mailing Address - Fax:508-756-2923
Practice Address - Street 1:59 QUINSIGAMOND AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-1867
Practice Address - Country:US
Practice Address - Phone:508-799-2550
Practice Address - Fax:508-756-2923
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2012-02-17
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
MA122221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT57152Medicare UPIN