Provider Demographics
NPI:1598902512
Name:KELLY, KENNETH BRIAN (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRIAN
Last Name:KELLY
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:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42135-0485
Mailing Address - Country:US
Mailing Address - Phone:270-586-4631
Mailing Address - Fax:270-586-4670
Practice Address - Street 1:201 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2722
Practice Address - Country:US
Practice Address - Phone:270-586-4631
Practice Address - Fax:270-586-4670
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7607122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist