Healthcare Provider Details

I. General information

NPI: 1215920632
Provider Name (Legal Business Name): FAMILY DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 NORTH ST
GRANVILLE NY
12832-1138
US

IV. Provider business mailing address

89 NORTH ST
GRANVILLE NY
12832-1138
US

V. Phone/Fax

Practice location:
  • Phone: 518-642-2111
  • Fax: 518-642-2891
Mailing address:
  • Phone: 518-642-2111
  • Fax: 518-642-2891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER R KELLEY
Title or Position: DENTIST
Credential: DDS
Phone: 518-642-2111