Healthcare Provider Details

I. General information

NPI: 1083756860
Provider Name (Legal Business Name): JOSEPH PATRICK KELLY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89574 545 AVE
CROFTON NE
68730-3238
US

IV. Provider business mailing address

89574 545 AVE
CROFTON NE
68730-3238
US

V. Phone/Fax

Practice location:
  • Phone: 206-948-2763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5907
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: