Provider Demographics
NPI:1588853352
Name:KELLY, JESUSA BEATRIZ PEREZ (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESUSA
Middle Name:BEATRIZ PEREZ
Last Name:KELLY
Suffix:
Gender:F
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:PO BOX 262202
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92196-2202
Mailing Address - Country:US
Mailing Address - Phone:858-622-0085
Mailing Address - Fax:
Practice Address - Street 1:8788 JAMACHA RD
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-4035
Practice Address - Country:US
Practice Address - Phone:619-515-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54271122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist