Provider Demographics
NPI:1437378965
Name:KELLEY, JOHN M JR (JOHN KELLEY, DDS, MS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:KELLEY
Suffix:JR
Gender:M
Credentials:JOHN KELLEY, DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 MERRIMAC CIR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-6571
Mailing Address - Country:US
Mailing Address - Phone:817-338-0771
Mailing Address - Fax:817-332-8072
Practice Address - Street 1:1533 MERRIMAC CIR
Practice Address - Street 2:SUITE 207
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-6571
Practice Address - Country:US
Practice Address - Phone:817-338-0771
Practice Address - Fax:817-332-8072
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX191321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics