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General NPI Number Information
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NPI Number | 1689763872
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Entity Type | Organization
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Legal Business Name | KEITH W KELLEY DDS PC
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 10/02/2007
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Provider Practice Location Address
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Address Line | 1913 W SOUTH BLVD
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City | TROY
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State | MI
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Zip | 48098
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Country | US
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Telephone | 248-828-3185
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Fax | 248-828-0197
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Provider Business Mailing Address
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Address Line | 1913 W SOUTH BLVD
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City | TROY
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State | MI
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Zip | 48098
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Country | US
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Telephone | 248-828-3185
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Fax | 248-828-0197
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | DR. KEITH W KELLEY
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Credential | DDS
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Telephone | 248-828-3185
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901013476
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License Number State | MI
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