Provider Demographics
NPI:1356460596
Name:KELLY, ERNEST MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
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 1:11615 ANGUS RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4078
Mailing Address - Country:US
Mailing Address - Phone:512-795-9643
Mailing Address - Fax:512-795-9959
Practice Address - Street 1:6211 W WILLIAM CANNON DR
Practice Address - Street 2:SUITE A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1923
Practice Address - Country:US
Practice Address - Phone:512-288-4447
Practice Address - Fax:512-288-4774
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9331122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist