Healthcare Provider Details

I. General information

NPI: 1649558412
Provider Name (Legal Business Name): PETER J KELLY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-6194
US

IV. Provider business mailing address

865 BALCH AVE
WINTER PARK FL
32789-4917
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-4833
  • Fax: 904-797-7128
Mailing address:
  • Phone: 407-629-2161
  • Fax: 407-629-2847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN19430
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: