Healthcare Provider Details

I. General information

NPI: 1770572828
Provider Name (Legal Business Name): THOMAS CHRISTOPHER KELLEY DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S CALHOUN RD
BROOKFIELD WI
53005-6303
US

IV. Provider business mailing address

150 S CALHOUN RD
BROOKFIELD WI
53005-6303
US

V. Phone/Fax

Practice location:
  • Phone: 262-787-9075
  • Fax: 262-787-9076
Mailing address:
  • Phone: 262-787-9075
  • Fax: 262-787-9076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5257015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: