Provider Demographics
NPI:1972640563
Name:TERRY M. KELLY DMD PA
Entity Type:Organization
Organization Name:TERRY M. KELLY DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:813-745-3968
Mailing Address - Street 1:701 S HOWARD AVE STE 106-307
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2473
Mailing Address - Country:US
Mailing Address - Phone:813-745-3968
Mailing Address - Fax:813-745-7464
Practice Address - Street 1:12902 MAGNOLIA DRIVE
Practice Address - Street 2:HEAD AND NECK CLINIC
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:813-979-3968
Practice Address - Fax:813-745-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN114071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5516Medicare ID - Type UnspecifiedGROUP