Provider Demographics
NPI:1467455147
Name:KELLY, KATHLEEN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 E MIFFLIN ST
Mailing Address - Street 2:STE 204
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-2895
Mailing Address - Country:US
Mailing Address - Phone:608-256-0499
Mailing Address - Fax:608-256-0577
Practice Address - Street 1:44 E MIFFLIN ST
Practice Address - Street 2:STE 204
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2895
Practice Address - Country:US
Practice Address - Phone:608-256-0499
Practice Address - Fax:608-256-0577
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001920-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33374700Medicaid