Provider Demographics
NPI:1649777905
Name:KELLEY, MATTHEW
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5343 ELM SPRING LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-1201
Mailing Address - Country:US
Mailing Address - Phone:469-417-9306
Mailing Address - Fax:
Practice Address - Street 1:UT SOUTHWESTERN MEDICAL CENTER 5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-0001
Practice Address - Country:US
Practice Address - Phone:214-645-3979
Practice Address - Fax:214-648-7620
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX392661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty