Healthcare Provider Details

I. General information

NPI: 1851491765
Provider Name (Legal Business Name): MICHAEL EDWARD KELLAM D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 02/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1064 INDUSTRIAL PKWY
SARALAND AL
36571-3720
US

IV. Provider business mailing address

1064 INDUSTRIAL PARKWAY
SARALAND AL
36571
US

V. Phone/Fax

Practice location:
  • Phone: 251-675-4313
  • Fax: 251-675-4355
Mailing address:
  • Phone: 251-675-4313
  • Fax: 251-675-4355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5252
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: