Provider Demographics
NPI:1578609673
Name:KELLEY, THOMAS HUDSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:HUDSON
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:600 N MOUNTAIN AVE
Mailing Address - Street 2:A204
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4359
Mailing Address - Country:US
Mailing Address - Phone:909-946-4477
Mailing Address - Fax:909-981-5586
Practice Address - Street 1:600 N MOUNTAIN AVE
Practice Address - Street 2:A204
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4359
Practice Address - Country:US
Practice Address - Phone:909-946-4477
Practice Address - Fax:909-981-5586
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA255581223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry