Healthcare Provider Details

I. General information

NPI: 1306808597
Provider Name (Legal Business Name): DEREK KELLY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1597 WASHINGTON PIKE STE A5
BRIDGEVILLE PA
15017-2881
US

IV. Provider business mailing address

926 GREAT POND DR SUITE 2003
ALTAMONTE SPRINGS FL
32714-7244
US

V. Phone/Fax

Practice location:
  • Phone: 412-279-4800
  • Fax: 412-279-7119
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS024337
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: