Provider Demographics
NPI:1629149372
Name:KELLY, PATRICK JAMES (DDS)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:JAMES
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 1:4009 FORT ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-4110
Mailing Address - Country:US
Mailing Address - Phone:313-928-8555
Mailing Address - Fax:313-928-1399
Practice Address - Street 1:4009 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-4110
Practice Address - Country:US
Practice Address - Phone:313-928-8555
Practice Address - Fax:313-928-1399
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3334958Medicaid