Provider Demographics
NPI:1710082649
Name:MCKELLOP, JOHN D (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:MCKELLOP
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 1:7800 US HIGHWAY 131 S
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-8437
Mailing Address - Country:US
Mailing Address - Phone:231-775-9797
Mailing Address - Fax:231-775-9793
Practice Address - Street 1:7800 US HIGHWAY 131 S
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-8437
Practice Address - Country:US
Practice Address - Phone:231-775-9797
Practice Address - Fax:231-775-9793
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11842122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist