Healthcare Provider Details

I. General information

NPI: 1497318992
Provider Name (Legal Business Name): KELLY FAMILY DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 S ARLINGTON AVE
RENO NV
89509-3309
US

IV. Provider business mailing address

1820 S ARLINGTON AVE
RENO NV
89509-3309
US

V. Phone/Fax

Practice location:
  • Phone: 775-329-8622
  • Fax:
Mailing address:
  • Phone: 775-329-8622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DAVID M KELLY
Title or Position: PRESIDENT/ DDS
Credential: DDS
Phone: 734-777-0289