Healthcare Provider Details

I. General information

NPI: 1780678748
Provider Name (Legal Business Name): JENNIFER RUTH KELLEY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 06/04/2012
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 Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number04287
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: