=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780998997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS C. KELLEY DDS MSD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2010
-----------------------------------------------------
Last Update Date | 07/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17280 W NORTH AVE STE 203
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53045-4366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-787-9075
-----------------------------------------------------
Fax | 262-787-9076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17280 W NORTH AVE STE 203
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53045-4366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-787-9075
-----------------------------------------------------
Fax | 262-787-9076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PERIODONTIST
-----------------------------------------------------
Name | DR. THOMAS C KELLEY
-----------------------------------------------------
Credential | DDS, MSD
-----------------------------------------------------
Telephone | 262-787-9075
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 5257015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------