Provider Demographics
NPI:1922060763
Name:KELLY, ROBERT J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:3901 LOUISIANA BLVD NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1577
Mailing Address - Country:US
Mailing Address - Phone:505-881-2421
Mailing Address - Fax:505-881-2841
Practice Address - Street 1:3901 LOUISIANA BLVD NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1577
Practice Address - Country:US
Practice Address - Phone:505-881-2421
Practice Address - Fax:505-881-2841
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMNMLL571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice