Healthcare Provider Details

I. General information

NPI: 1285882977
Provider Name (Legal Business Name): RUSSELL A. KELLY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 N TUSTIN ST
ORANGE CA
92867-5902
US

IV. Provider business mailing address

951 N TUSTIN ST
ORANGE CA
92867-5902
US

V. Phone/Fax

Practice location:
  • Phone: 714-532-3331
  • Fax: 714-532-5886
Mailing address:
  • Phone: 714-532-3331
  • Fax: 714-532-5886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number43284
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: