MEDICARE: DR. JUSTINA MARIE KELLY D.M.D.

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	122300000X	Dentist	DS040386	PA

General Provider Information

NPI Number	:	1659750107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTINA MARIE KELLY D.M.D.

Provider Business Mailing Address
First Line	:	10590 ENDURING FREEDOM DR
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13602-5005
Country	:	US
Telephone Number	:	315-772-6234
Fax Number	:

Provider Business Practice Location Address
First Line	:	6502 STEUBENVILLE PIKE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15205-1006
Country	:	US
Telephone Number	:	412-200-2614
Fax Number	:

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

Provider Enumeration Date	:	05/28/2015
Last Update Date	:	04/18/2019

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