Provider Demographics
NPI:1649558412
Name:KELLY, PETER J (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
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 1:865 BALCH AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4917
Mailing Address - Country:US
Mailing Address - Phone:407-629-2161
Mailing Address - Fax:407-629-2847
Practice Address - Street 1:2520 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6194
Practice Address - Country:US
Practice Address - Phone:904-797-4833
Practice Address - Fax:904-797-7128
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist