Provider Demographics
NPI:1912441064
Name:SHAWN KELLY DDS INC
Entity Type:Organization
Organization Name:SHAWN KELLY DDS INC
Other - Org Name:ROSEVILLE DENTAL GROUP SLEEP SOLUTIONS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-773-1122
Mailing Address - Street 1:700 SUNRISE AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4561
Mailing Address - Country:US
Mailing Address - Phone:916-773-1122
Mailing Address - Fax:916-773-3528
Practice Address - Street 1:700 SUNRISE AVE
Practice Address - Street 2:SUITE E
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4561
Practice Address - Country:US
Practice Address - Phone:916-773-1122
Practice Address - Fax:916-773-3528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29984332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment