Provider Demographics
NPI:1619338761
Name:KELLY FAMILY DENTISTRY
Entity Type:Organization
Organization Name:KELLY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHENIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:769-572-4425
Mailing Address - Street 1:514 E WOODROW WILSON AVE STE G
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4538
Mailing Address - Country:US
Mailing Address - Phone:769-572-4425
Mailing Address - Fax:844-270-0967
Practice Address - Street 1:514 E WOODROW WILSON AVE STE G
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4538
Practice Address - Country:US
Practice Address - Phone:769-572-4425
Practice Address - Fax:844-270-0967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS364412261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental