Healthcare Provider Details

I. General information

NPI: 1508927757
Provider Name (Legal Business Name): TERENCE PATRICK KELLY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GYPSY LN
YOUNGSTOWN OH
44504
US

IV. Provider business mailing address

7649 EARLINGTON PKWY
DUBLIN OH
43017-3424
US

V. Phone/Fax

Practice location:
  • Phone: 330-884-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30-017132
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number57.246804
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: