Provider Demographics
NPI:1427224757
Name:KELLEY, BRIAN WILLIAM (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
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Mailing Address - Street 1:3839 W CONGRESS ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-6000
Mailing Address - Country:US
Mailing Address - Phone:337-984-0403
Mailing Address - Fax:337-981-9006
Practice Address - Street 1:3839 W CONGRESS ST
Practice Address - Street 2:SUITE C
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-6000
Practice Address - Country:US
Practice Address - Phone:337-984-0403
Practice Address - Fax:337-981-9006
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA58551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery