Provider Demographics
NPI:1700203247
Name:ANDREW W KELLY DDS PLLC
Entity Type:Organization
Organization Name:ANDREW W KELLY DDS PLLC
Other - Org Name:DENTAL CENTER OF THE CAROLINAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-766-7966
Mailing Address - Street 1:4164 CLEMMONS RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-7520
Mailing Address - Country:US
Mailing Address - Phone:336-766-7966
Mailing Address - Fax:
Practice Address - Street 1:4164 CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-7520
Practice Address - Country:US
Practice Address - Phone:336-766-7966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-22
Last Update Date:2014-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7350261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental