Provider Demographics
NPI:1457135451
Name:KELLY, DAVID JADE (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JADE
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 1:125 E MERRITT CSWY STE 127
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3697
Mailing Address - Country:US
Mailing Address - Phone:321-449-9300
Mailing Address - Fax:321-449-9338
Practice Address - Street 1:125 E MERRITT CSWY STE 127
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3697
Practice Address - Country:US
Practice Address - Phone:321-449-9300
Practice Address - Fax:321-449-9338
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN285211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice