Provider Demographics
NPI:1710433123
Name:TIMOTHY L KELLY DENTAL PROF. LLC
Entity Type:Organization
Organization Name:TIMOTHY L KELLY DENTAL PROF. LLC
Other - Org Name:RUSHMORE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-593-0037
Mailing Address - Street 1:1600 MOUNTAIN VIEW RD STE 104
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-4354
Mailing Address - Country:US
Mailing Address - Phone:605-593-0037
Mailing Address - Fax:605-593-8351
Practice Address - Street 1:1600 MOUNTAIN VIEW RD STE 104
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-4354
Practice Address - Country:US
Practice Address - Phone:605-593-0037
Practice Address - Fax:605-593-8351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-27
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD0505122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1588653281Medicaid