Provider Demographics
NPI:1477585651
Name:KELLEY, CHERYL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 WHITE SPRUCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1604
Mailing Address - Country:US
Mailing Address - Phone:585-424-5005
Mailing Address - Fax:585-475-0096
Practice Address - Street 1:370 WHITE SPRUCE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1604
Practice Address - Country:US
Practice Address - Phone:585-424-5005
Practice Address - Fax:585-475-0096
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0368861223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01039505Medicaid
NY9561OtherBC/BS #