Provider Demographics
NPI:1881333235
Name:KELLY, ANDREW COLLIN (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:COLLIN
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 1:374TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 5071
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:374TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5071
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328
Practice Address - Country:US
Practice Address - Phone:315-225-8864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODEN.00205260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program