Provider Demographics
NPI:1801022256
Name:WILLIAM M. KELLY, D.D.S., M.S., LTD
Entity Type:Organization
Organization Name:WILLIAM M. KELLY, D.D.S., M.S., LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:630-584-9666
Mailing Address - Street 1:11 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2706
Mailing Address - Country:US
Mailing Address - Phone:630-584-9666
Mailing Address - Fax:630-584-9681
Practice Address - Street 1:11 S 6TH ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2706
Practice Address - Country:US
Practice Address - Phone:630-584-9666
Practice Address - Fax:630-584-9681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190138531223X0400X
IL0190260741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty