Provider Demographics
NPI:1124048491
Name:KELLY, DAVID RANDOLPH (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RANDOLPH
Last Name:KELLY
Suffix:
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 1:1941 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-3607
Mailing Address - Country:US
Mailing Address - Phone:276-669-0112
Mailing Address - Fax:276-669-6922
Practice Address - Street 1:1941 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-3607
Practice Address - Country:US
Practice Address - Phone:276-669-0112
Practice Address - Fax:276-669-6922
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010061671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
021225OtherANTHEM
TN0064919OtherBCBS
VA9178719Medicaid