Provider Demographics
NPI:1750522041
Name:MICHAEL E. KELLAM DMD, PC
Entity type:Organization
Organization Name:MICHAEL E. KELLAM DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD, PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-675-8150
Mailing Address - Street 1:1064 INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:SARALAND
Mailing Address - State:AL
Mailing Address - Zip Code:36571-3720
Mailing Address - Country:US
Mailing Address - Phone:251-675-8150
Mailing Address - Fax:251-675-8152
Practice Address - Street 1:1064 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-3720
Practice Address - Country:US
Practice Address - Phone:251-675-8150
Practice Address - Fax:251-675-8152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL52521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009937656Medicaid
AL515-11923OtherBLUE CROSS BLUE SHIELD
AL515-11923OtherBLUE CROSS BLUE SHIELD