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General NPI Number Information
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NPI Number | 1871917179
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Entity Type | Organization
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Legal Business Name | KELLY FAMILY ORTHODONTICS
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Dates
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Enumeration Date | 02/07/2014
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Last Update Date | 02/07/2014
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Provider Practice Location Address
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Address Line | 30 MEADOWRUE DR
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City | GLASTONBURY
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State | CT
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Zip | 06033-4357
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Country | US
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Telephone | 207-333-2685
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Fax |
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Provider Business Mailing Address
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Address Line | 30 MEADOWRUE DR
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City | GLASTONBURY
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State | CT
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Zip | 06033-4357
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Country | US
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Telephone | 207-333-2685
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | GILLIAN R KELLY
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Credential |
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Telephone | 207-333-2685
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 10949
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License Number State | CT
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