Provider Demographics
NPI:1740407501
Name:KELLY, NEIL (DD S)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:DD S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E RED BRIDGE RD
Mailing Address - Street 2:SUITE 119
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4035
Mailing Address - Country:US
Mailing Address - Phone:816-942-8550
Mailing Address - Fax:816-942-0790
Practice Address - Street 1:400 E RED BRIDGE RD
Practice Address - Street 2:SUITE 119
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-4035
Practice Address - Country:US
Practice Address - Phone:816-942-8550
Practice Address - Fax:816-942-0790
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS66831223G0001X
MO0152301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice