Provider Demographics
NPI:1457523805
Name:KELLEY FAMILY DENTISTRY
Entity Type:Organization
Organization Name:KELLEY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRON
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-852-2564
Mailing Address - Street 1:35 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1239
Mailing Address - Country:US
Mailing Address - Phone:208-852-2564
Mailing Address - Fax:
Practice Address - Street 1:35 S STATE ST
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1239
Practice Address - Country:US
Practice Address - Phone:208-852-2564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3719122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty