Provider Demographics
NPI:1356372262
Name:KELTY, GLENN E (DDS)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:E
Last Name:KELTY
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 1:1914 S POWER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4376
Mailing Address - Country:US
Mailing Address - Phone:480-641-4633
Mailing Address - Fax:480-641-9432
Practice Address - Street 1:1914 S POWER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4376
Practice Address - Country:US
Practice Address - Phone:480-641-4633
Practice Address - Fax:480-641-9432
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD16401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice