Provider Demographics
NPI:1972945509
Name:KELLY, JOSEPH T SR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:T
Last Name:KELLY
Suffix:SR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W GROVE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2062
Mailing Address - Country:US
Mailing Address - Phone:570-587-4787
Mailing Address - Fax:570-586-2375
Practice Address - Street 1:103 W GROVE ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-2062
Practice Address - Country:US
Practice Address - Phone:570-587-4787
Practice Address - Fax:570-586-2375
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017660L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist