Provider Demographics
NPI:1770572828
Name:KELLEY, THOMAS CHRISTOPHER (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CHRISTOPHER
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S CALHOUN RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6303
Mailing Address - Country:US
Mailing Address - Phone:262-787-9075
Mailing Address - Fax:262-787-9076
Practice Address - Street 1:150 S CALHOUN RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6303
Practice Address - Country:US
Practice Address - Phone:262-787-9075
Practice Address - Fax:262-787-9076
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52570151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33778000Medicaid