Provider Demographics
NPI:1528220480
Name:YU, KELLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:YU
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 1:313 6TH AVE
Mailing Address - Street 2:APT 1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-4445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:313 6TH AVE
Practice Address - Street 2:APT 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-4445
Practice Address - Country:US
Practice Address - Phone:646-912-9322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY054622122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03191513Medicaid