Provider Demographics
NPI:1558736991
Name:TIMOTHY M. KELLY, DMD, PA
Entity Type:Organization
Organization Name:TIMOTHY M. KELLY, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PA
Authorized Official - Phone:505-256-1770
Mailing Address - Street 1:1441 CARLISLE BLVD NE
Mailing Address - Street 2:SUITE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5610
Mailing Address - Country:US
Mailing Address - Phone:505-256-1770
Mailing Address - Fax:505-255-0220
Practice Address - Street 1:1441 CARLISLE BLVD NE
Practice Address - Street 2:SUITE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5610
Practice Address - Country:US
Practice Address - Phone:505-256-1770
Practice Address - Fax:505-255-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM14131223D0001X, 332BC3200X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty