Provider Demographics
NPI:1588653281
Name:KELLY, TIMOTHY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:LYNN
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 1:1600 MOUNTAIN VIEW RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-4381
Mailing Address - Country:US
Mailing Address - Phone:605-593-0037
Mailing Address - Fax:605-593-8351
Practice Address - Street 1:1600 MOUNTAIN VIEW RD
Practice Address - Street 2:SUITE 104
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-4381
Practice Address - Country:US
Practice Address - Phone:605-593-0037
Practice Address - Fax:605-593-8351
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD0505122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist