Provider Demographics
NPI:1497836126
Name:KELLEY, SUSAN L (DO)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:L
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3275 LOWER RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-1458
Mailing Address - Country:US
Mailing Address - Phone:808-433-8902
Mailing Address - Fax:808-433-3890
Practice Address - Street 1:MCCORNACK ROAD BLDG 660
Practice Address - Street 2:
Practice Address - City:SCHOFIELD BARRACKS
Practice Address - State:HI
Practice Address - Zip Code:96857
Practice Address - Country:US
Practice Address - Phone:808-433-8902
Practice Address - Fax:808-433-8909
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-14961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIDT-1496OtherHI STATE LICENSE