Healthcare Provider Details

I. General information

NPI: 1932485380
Provider Name (Legal Business Name): DR. STEPHEN A. KELLAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 HARKLE RD STE D
SANTA FE NM
87505-4783
US

IV. Provider business mailing address

539 HARKLE RD STE D
SANTA FE NM
87505-4783
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-5531
  • Fax:
Mailing address:
  • Phone: 505-982-5531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1798
License Number StateNM

VIII. Authorized Official

Name: STEPHEN A KELLAM
Title or Position: PRESIDENT/OWNER
Credential: D.M.D., M.S.
Phone: 505-982-5531