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General NPI Number Information
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NPI Number | 1063764579
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Entity Type | Organization
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Legal Business Name | KELLY FAMILY DENTISTRY
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Dates
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Enumeration Date | 10/08/2012
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Last Update Date | 10/08/2012
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Provider Practice Location Address
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Address Line | 2412 W FAIDLEY AVE
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City | GRAND ISLAND
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State | NE
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Zip | 68803-4327
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Country | US
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Telephone | 308-389-2811
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Fax | 308-389-2871
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Provider Business Mailing Address
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Address Line | 2412 W FAIDLEY AVE
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City | GRAND ISLAND
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State | NE
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Zip | 68803-4327
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Country | US
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Telephone | 308-389-2811
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Fax | 308-389-2871
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | BRAD JAMES KELLY
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Credential | D.D.S.
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Telephone | 308-389-2811
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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