Healthcare Provider Details

I. General information

NPI: 1265888655
Provider Name (Legal Business Name): MICHAEL C KELLY D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 W LAKE ST
CHICAGO IL
60644-2342
US

IV. Provider business mailing address

568 S SPRING RD STE A
ELMHURST IL
60126-3868
US

V. Phone/Fax

Practice location:
  • Phone: 773-378-3347
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number19030568
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: