Provider Demographics
NPI:1588805311
Name:KELLEY, EUGENE OWEN (DMD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:OWEN
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 SW CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3001
Mailing Address - Country:US
Mailing Address - Phone:503-494-0292
Mailing Address - Fax:503-494-0294
Practice Address - Street 1:611 SW CAMPUS DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3001
Practice Address - Country:US
Practice Address - Phone:503-494-0292
Practice Address - Fax:503-494-0294
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD34521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery