Provider Demographics
NPI:1801942289
Name:KELLEY, JOHN ROY JR (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROY
Last Name:KELLEY
Suffix:JR
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 1:9000 GOLFSIDE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7793
Mailing Address - Country:US
Mailing Address - Phone:904-367-1722
Mailing Address - Fax:904-367-1739
Practice Address - Street 1:3733 SOUTHSIDE BLVD
Practice Address - Street 2:SUITES 5 & 6
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4684
Practice Address - Country:US
Practice Address - Phone:904-996-0111
Practice Address - Fax:904-996-0140
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN29271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice