Healthcare Provider Details

I. General information

NPI: 1558736991
Provider Name (Legal Business Name): TIMOTHY M. KELLY, DMD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 CARLISLE BLVD NE SUITE D
ALBUQUERQUE NM
87110-5610
US

IV. Provider business mailing address

1441 CARLISLE BLVD NE SUITE D
ALBUQUERQUE NM
87110-5610
US

V. Phone/Fax

Practice location:
  • Phone: 505-256-1770
  • Fax: 505-255-0220
Mailing address:
  • Phone: 505-256-1770
  • Fax: 505-255-0220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number1413
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number1413
License Number StateNM

VIII. Authorized Official

Name: DR. TIMOTHY M KELLY
Title or Position: OWNER/DENTIST
Credential: DMD, PA
Phone: 505-256-1770