Provider Demographics
NPI:1982757456
Name:KELLY, PATRICK DALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:DALE
Last Name:KELLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 HWY 12 WEST
Mailing Address - Street 2:BOX 710
Mailing Address - City:BOWMAN
Mailing Address - State:ND
Mailing Address - Zip Code:58623-0710
Mailing Address - Country:US
Mailing Address - Phone:701-523-3255
Mailing Address - Fax:701-523-5742
Practice Address - Street 1:608 HWY 12 WEST
Practice Address - Street 2:
Practice Address - City:BOWMAN
Practice Address - State:ND
Practice Address - Zip Code:58623-0710
Practice Address - Country:US
Practice Address - Phone:701-523-3255
Practice Address - Fax:701-523-5742
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40965Medicaid