MEDICARE: MARK T KELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5869	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1888656	OTHER	OK	UNITED CONCORDIA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578656393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK T KELLY

Provider Business Mailing Address
First Line	:	415 N GRAND AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-3111
Country	:	US
Telephone Number	:	719-546-3333
Fax Number	:

Provider Business Practice Location Address
First Line	:	3637 NW 39TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-6309
Country	:	US
Telephone Number	:	405-942-7755
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/09/2007

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