Provider Demographics
NPI:1902023757
Name:KELLY, DENNIS A (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 NEILSON WAY
Mailing Address - Street 2:403
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405
Mailing Address - Country:US
Mailing Address - Phone:310-396-3980
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY PARK HELATH CTR
Practice Address - Street 2:849 W 34TH ST
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0311
Practice Address - Country:US
Practice Address - Phone:213-740-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26518208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice