Healthcare Provider Details

I. General information

NPI: 1972640563
Provider Name (Legal Business Name): TERRY M. KELLY DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 MAGNOLIA DRIVE HEAD AND NECK CLINIC
TAMPA FL
33612
US

IV. Provider business mailing address

701 S HOWARD AVE STE 106-307
TAMPA FL
33606-2473
US

V. Phone/Fax

Practice location:
  • Phone: 813-979-3968
  • Fax: 813-745-7464
Mailing address:
  • Phone: 813-745-3968
  • Fax: 813-745-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN11407
License Number StateFL

VIII. Authorized Official

Name: DR. TERRY MICHAEL KELLY
Title or Position: OWNER DENTIST
Credential: DMD
Phone: 813-745-3968