=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174912422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLDENTAL P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2015
-----------------------------------------------------
Last Update Date | 01/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1121 S MCKENZIE ST
-----------------------------------------------------
City | FOLEY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36535-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-970-2333
-----------------------------------------------------
Fax | 251-970-2334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1121 S MCKENZIE ST
-----------------------------------------------------
City | FOLEY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36535-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-970-2333
-----------------------------------------------------
Fax | 251-970-2334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | PATRICK BRITTON KELLY
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 251-970-2333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4713
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------