Healthcare Provider Details

I. General information

NPI: 1285979625
Provider Name (Legal Business Name): JILL ALLISON KELLY IPDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 RT. 109
ACTON ME
04001
US

IV. Provider business mailing address

PO BOX 48
ACTON ME
04001-0048
US

V. Phone/Fax

Practice location:
  • Phone: 207-604-9027
  • Fax:
Mailing address:
  • Phone: 207-604-9027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number52
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: