Provider Demographics
NPI:1386685022
Name:KELLY, JOHN PATRICK WASHINGTON (MD, DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PATRICK WASHINGTON
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 CHAPEL ST
Mailing Address - Street 2:MOB-2
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4405
Mailing Address - Country:US
Mailing Address - Phone:203-789-3156
Mailing Address - Fax:203-789-3954
Practice Address - Street 1:1450 CHAPEL ST
Practice Address - Street 2:MOB-2
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4405
Practice Address - Country:US
Practice Address - Phone:203-789-3156
Practice Address - Fax:203-789-3954
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0087831223S0112X
CT038903204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD85825Medicare UPIN