Provider Demographics
NPI:1598133894
Name:KELLY, MATTHEW JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
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:PSC 466 BOX 3
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96595-0001
Mailing Address - Country:US
Mailing Address - Phone:315-370-4153
Mailing Address - Fax:
Practice Address - Street 1:YOKOSUKA INAOKACHO
Practice Address - Street 2:, 82 YOKOSUKA
Practice Address - City:YOKOSUKA
Practice Address - State:KANAGAWA
Practice Address - Zip Code:238-0001
Practice Address - Country:JP
Practice Address - Phone:315-370-4153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist