Provider Demographics
NPI:1760592851
Name:KELLY, GEORGE PETER (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:PETER
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 1:101 SOUTH FRONT ST
Mailing Address - Street 2:SUITE 509
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4641
Mailing Address - Country:US
Mailing Address - Phone:906-228-6830
Mailing Address - Fax:906-228-6842
Practice Address - Street 1:101 SOUTH FRONT ST
Practice Address - Street 2:SUITE 509
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4641
Practice Address - Country:US
Practice Address - Phone:906-228-6830
Practice Address - Fax:906-228-6842
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901009757122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223P0300XDental ProvidersDentistPeriodontics