Provider Demographics
NPI:1629079470
Name:KELLEY, GREG ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:ALAN
Last Name:KELLEY
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 1:109 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-3510
Mailing Address - Country:US
Mailing Address - Phone:620-331-3180
Mailing Address - Fax:620-331-3170
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-3510
Practice Address - Country:US
Practice Address - Phone:620-331-3180
Practice Address - Fax:620-331-3170
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS63811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice