=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114417045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIE PETTERS KELLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2018
-----------------------------------------------------
Last Update Date | 05/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1670 LINCOLN HWY E
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17602-2663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-394-1067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1670 LINCOLN HWY E
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17602-2663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-394-1067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GM
-----------------------------------------------------
Name | DANIEL KELLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 717-925-4327
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DS035577
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DS040000
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DS025788L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------