=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396726758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELBERT R KELLY DDS & ASSOC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1042 E 3RD ST STE 201
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-265-0419
-----------------------------------------------------
Fax | 423-265-3334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1042 E 3RD ST STE 201
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-265-0419
-----------------------------------------------------
Fax | 423-265-3334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. DELBERT R KELLY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 423-265-0419
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS4101
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------