Healthcare Provider Details

I. General information

NPI: 1295464709
Provider Name (Legal Business Name): MARTIN KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/09/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 FLOWOOD DR STE A
FLOWOOD MS
39232-9358
US

IV. Provider business mailing address

304 AUTUMN COVE
MADISON MS
39110
US

V. Phone/Fax

Practice location:
  • Phone: 601-939-4100
  • Fax:
Mailing address:
  • Phone: 601-946-0186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4274-22
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: