Provider Demographics
NPI:1396726758
Name:DELBERT R KELLY DDS & ASSOC
Entity type:Organization
Organization Name:DELBERT R KELLY DDS & ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DELBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-265-0419
Mailing Address - Street 1:1042 E 3RD ST
Mailing Address - Street 2:STE 201
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403
Mailing Address - Country:US
Mailing Address - Phone:423-265-0419
Mailing Address - Fax:423-265-3334
Practice Address - Street 1:1042 E 3RD ST
Practice Address - Street 2:STE 201
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403
Practice Address - Country:US
Practice Address - Phone:423-265-0419
Practice Address - Fax:423-265-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS4101122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225019Medicaid