Provider Demographics
NPI:1811101876
Name:KELLY, ROBERT H (DMD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:KELLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24540 E WELCHES RD
Mailing Address - Street 2:
Mailing Address - City:WELCHES
Mailing Address - State:OR
Mailing Address - Zip Code:97067-0347
Mailing Address - Country:US
Mailing Address - Phone:503-622-3085
Mailing Address - Fax:
Practice Address - Street 1:24540 E WELCHES RD
Practice Address - Street 2:
Practice Address - City:WELCHES
Practice Address - State:OR
Practice Address - Zip Code:97067-0347
Practice Address - Country:US
Practice Address - Phone:503-622-3085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI21141223G0001X
ORD9179122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice