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General NPI Number Information
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NPI Number | 1447821319
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Entity Type | Organization
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Legal Business Name | JACOB D KELLY DDS, INC.
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Dates
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Enumeration Date | 07/01/2021
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Last Update Date | 07/01/2021
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Provider Practice Location Address
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Address Line | 2360 PROFESSIONAL DR STE 100
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City | ROSEVILLE
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State | CA
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Zip | 95661-7782
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Country | US
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Telephone | 916-782-9479
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Fax | 916-782-3342
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Provider Business Mailing Address
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Address Line | 2360 PROFESSIONAL DR STE 100
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City | ROSEVILLE
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State | CA
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Zip | 95661-7782
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Country | US
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Telephone | 916-782-9479
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Fax | 916-782-3342
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | DR. JACOB DEAN KELLY
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Credential | DDS
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Telephone | 916-782-9479
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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