Provider Demographics
NPI:1447202148
Name:KELLY, PAUL JOHN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JOHN
Last Name:KELLY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:726 N GREENFIELD RD
Mailing Address - Street 2:SUITE #117
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-5061
Mailing Address - Country:US
Mailing Address - Phone:480-685-9696
Mailing Address - Fax:480-378-3565
Practice Address - Street 1:726 N GREENFIELD RD
Practice Address - Street 2:SUITE 117
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-5061
Practice Address - Country:US
Practice Address - Phone:480-685-9696
Practice Address - Fax:480-378-3565
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD69131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD6913OtherDENTAL LICENSE