Provider Demographics
NPI:1922435148
Name:KELLY DENTAL LLC
Entity Type:Organization
Organization Name:KELLY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHASE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:417-881-1213
Mailing Address - Street 1:1655 S ENTERPRISE AVE STE A3
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1864
Mailing Address - Country:US
Mailing Address - Phone:417-881-1213
Mailing Address - Fax:417-877-8156
Practice Address - Street 1:1655 S. ENTERPRISE AVE STE. A-3
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-881-1213
Practice Address - Fax:417-877-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013017374261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental