Provider Demographics
NPI:1750588059
Name:KELLY, TERRY MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10150 HIGHLAND MANOR DR
Mailing Address - Street 2:SUITE 145
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-9713
Mailing Address - Country:US
Mailing Address - Phone:813-682-2401
Mailing Address - Fax:813-682-2402
Practice Address - Street 1:10150 HIGHLAND MANOR DR
Practice Address - Street 2:SUITE 145
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-9713
Practice Address - Country:US
Practice Address - Phone:813-682-2401
Practice Address - Fax:813-682-2402
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLDN114071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN11407OtherLICENSE