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General NPI Number Information
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NPI Number | 1700203247
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Entity Type | Organization
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Legal Business Name | ANDREW W KELLY DDS PLLC
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Dates
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Enumeration Date | 03/22/2014
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Last Update Date | 03/22/2014
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Provider Practice Location Address
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Address Line | 4164 CLEMMONS RD
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City | CLEMMONS
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State | NC
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Zip | 27012-7520
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Country | US
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Telephone | 336-766-7966
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Fax |
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Provider Business Mailing Address
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Address Line | 4164 CLEMMONS RD
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City | CLEMMONS
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State | NC
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Zip | 27012-7520
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Country | US
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Telephone | 336-766-7966
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Fax |
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Authorized Official
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Title or Position | MANAGER/DENTIST
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Name | ANDREW WAYNE KELLY
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Credential | DDS
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Telephone | 336-766-7966
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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 | 7350
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License Number State | NC
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