Provider Demographics
NPI:1477632396
Name:KELLY, SCOTT S (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:S
Last Name:KELLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W JOHN ST
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-2145
Mailing Address - Country:US
Mailing Address - Phone:419-893-6971
Mailing Address - Fax:419-893-1137
Practice Address - Street 1:116 W JOHN ST
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-2145
Practice Address - Country:US
Practice Address - Phone:419-893-6971
Practice Address - Fax:419-893-1137
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0215467Medicaid