Provider Demographics
NPI:1134554165
Name:KELLY, GILLIAN R (DMD,MSD)
Entity type:Individual
Prefix:DR
First Name:GILLIAN
Middle Name:R
Last Name:KELLY
Suffix:
Gender:F
Credentials:DMD,MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4791
Mailing Address - Country:US
Mailing Address - Phone:860-346-9259
Mailing Address - Fax:860-346-9250
Practice Address - Street 1:561 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4791
Practice Address - Country:US
Practice Address - Phone:860-346-9259
Practice Address - Fax:860-346-9250
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT109491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics