Provider Demographics
NPI:1952333676
Name:KELLY, PATRICK JAMES SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JAMES
Last Name:KELLY
Suffix:SR
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 1:35992 S GRATIOT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1776
Mailing Address - Country:US
Mailing Address - Phone:586-790-7360
Mailing Address - Fax:586-790-8860
Practice Address - Street 1:35992 S GRATIOT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-1776
Practice Address - Country:US
Practice Address - Phone:586-790-7360
Practice Address - Fax:586-790-8860
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010098981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice