Provider Demographics
NPI:1376263541
Name:KELLY CHONG DDS PA
Entity Type:Organization
Organization Name:KELLY CHONG DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-282-3232
Mailing Address - Street 1:12278 E COLONIAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12278 E COLONIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4734
Practice Address - Country:US
Practice Address - Phone:407-282-3232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental