Provider Demographics
NPI:1932611092
Name:A W KELLY DDS PLLC
Entity Type:Organization
Organization Name:A W KELLY DDS PLLC
Other - Org Name:DENTAL CENTER OF THE CAROLINAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-766-7966
Mailing Address - Street 1:137 N HIDDENBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:NC
Mailing Address - Zip Code:27006-7299
Mailing Address - Country:US
Mailing Address - Phone:336-766-7966
Mailing Address - Fax:
Practice Address - Street 1:4550 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3518
Practice Address - Country:US
Practice Address - Phone:333-766-7966
Practice Address - Fax:877-840-4367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC073501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1992888242Medicaid