Provider Demographics
NPI:1952761819
Name:JOSEPH T KELLY, DDS PC
Entity Type:Organization
Organization Name:JOSEPH T KELLY, DDS PC
Other - Org Name:GREAT IMPRESSION DENTAL PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:660-882-7522
Mailing Address - Street 1:1480 W ASHLEY RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-2141
Mailing Address - Country:US
Mailing Address - Phone:660-882-7522
Mailing Address - Fax:660-882-9022
Practice Address - Street 1:1480 W ASHLEY RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2141
Practice Address - Country:US
Practice Address - Phone:660-882-7522
Practice Address - Fax:660-882-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014008013122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty