Provider Demographics
NPI:1295783462
Name:GALLAGHER, KELLY ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ROBERT
Last Name:GALLAGHER
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 1:216 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-3646
Mailing Address - Country:US
Mailing Address - Phone:507-289-5838
Mailing Address - Fax:507-536-2762
Practice Address - Street 1:216 N BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-3646
Practice Address - Country:US
Practice Address - Phone:507-289-5838
Practice Address - Fax:507-536-2762
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN92641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice