=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003212937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY PALCHIK DMD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2014
-----------------------------------------------------
Last Update Date | 11/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 84 MAIN ST S
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06798-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-263-2853
-----------------------------------------------------
Fax | 203-263-2859
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84 MAIN ST S PO BOX 407
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06798-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-263-2853
-----------------------------------------------------
Fax | 203-263-2859
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KELLY PALCHIK
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 203-263-2853
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 010935
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------