Provider Demographics
NPI:1659427318
Name:KELLY, TIMOTHY MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MARK
Last Name:KELLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 CARLISLE BLVD NE
Mailing Address - Street 2:SUITE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5610
Mailing Address - Country:US
Mailing Address - Phone:505-256-1770
Mailing Address - Fax:505-255-0220
Practice Address - Street 1:1441 CARLISLE BLVD NE
Practice Address - Street 2:SUITE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5610
Practice Address - Country:US
Practice Address - Phone:505-256-1770
Practice Address - Fax:505-255-0220
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM14131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20-8114933OtherEIN