=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346480019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALD BRYAN KELLEY D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2009
-----------------------------------------------------
Last Update Date | 02/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5303 SKEENS RIDGE RD
-----------------------------------------------------
City | BIG STONE GAP
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24219-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-523-1652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5303 SKEENS RIDGE RD
-----------------------------------------------------
City | BIG STONE GAP
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24219-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-523-1652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401003752
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------