Healthcare Provider Details

I. General information

NPI: 1639271117
Provider Name (Legal Business Name): PATRICK TADHG KELLY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 MIDDLE ISLAND POINT RD
MARQUETTE MI
49855-9726
US

IV. Provider business mailing address

17 MIDDLE ISLAND POINT RD
MARQUETTE MI
49855-9726
US

V. Phone/Fax

Practice location:
  • Phone: 906-228-9535
  • Fax:
Mailing address:
  • Phone: 906-228-9535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901008589
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: