Provider Demographics
NPI:1013082189
Name:KELLY, SHAWN PATRICK (DMD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:PATRICK
Last Name:KELLY
Suffix:
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 1:182 WHITE CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-3409
Mailing Address - Country:US
Mailing Address - Phone:609-707-1032
Mailing Address - Fax:
Practice Address - Street 1:13 SOMERDALE SQ
Practice Address - Street 2:
Practice Address - City:SOMERDALE
Practice Address - State:NJ
Practice Address - Zip Code:08083-1345
Practice Address - Country:US
Practice Address - Phone:856-566-6969
Practice Address - Fax:856-566-6012
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022607001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice