Healthcare Provider Details

I. General information

NPI: 1952761819
Provider Name (Legal Business Name): JOSEPH T KELLY, DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 W ASHLEY RD
BOONVILLE MO
65233-2141
US

IV. Provider business mailing address

1480 W ASHLEY RD
BOONVILLE MO
65233-2141
US

V. Phone/Fax

Practice location:
  • Phone: 660-882-7522
  • Fax: 660-882-9022
Mailing address:
  • Phone: 660-882-7522
  • Fax: 660-882-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2014008013
License Number StateMO

VIII. Authorized Official

Name: DR. JOSEPH THOMAS KELLY
Title or Position: PRESIDENT-OWNER
Credential: DDS
Phone: 660-882-7522