Provider Demographics
NPI:1407840580
Name:KELLY, MICHAEL THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
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 1:9377 E BELL RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1502
Mailing Address - Country:US
Mailing Address - Phone:480-513-2620
Mailing Address - Fax:
Practice Address - Street 1:9377 E BELL RD
Practice Address - Street 2:SUITE 301
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1502
Practice Address - Country:US
Practice Address - Phone:480-513-2620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0013369122300000X
AZD7706122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist