Provider Demographics
NPI:1619909793
Name:KELLY, DENNIS G (DO)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:G
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:27483 DEQUINDRE
Mailing Address - Street 2:SUITE 303A
Mailing Address - City:MADISON HGTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071
Mailing Address - Country:US
Mailing Address - Phone:248-398-4614
Mailing Address - Fax:248-398-4345
Practice Address - Street 1:27483 DEQUINDRE RD
Practice Address - Street 2:SUITE 303A
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3491
Practice Address - Country:US
Practice Address - Phone:248-398-4614
Practice Address - Fax:248-398-4345
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDK008799207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI112727880Medicaid
MIDK008799OtherSTATE LIC
MI112727880Medicaid
MI5631153Medicare ID - Type UnspecifiedMEDICARE