Provider Demographics
NPI:1720195183
Name:KELLY, GARY GERALD (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:GERALD
Last Name:KELLY
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 1:2656 E 29TH
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223
Mailing Address - Country:US
Mailing Address - Phone:509-535-7791
Mailing Address - Fax:509-535-1833
Practice Address - Street 1:2656 E 29TH
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223
Practice Address - Country:US
Practice Address - Phone:509-535-7791
Practice Address - Fax:509-535-1833
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005661122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5040506Medicaid
623104OtherUN CONCORDIA
82344OtherL & I