=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932485380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. STEPHEN A. KELLAM, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2011
-----------------------------------------------------
Last Update Date | 10/31/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 539 HARKLE RD STE D
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-982-5531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 539 HARKLE RD STE D
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-982-5531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | STEPHEN A KELLAM
-----------------------------------------------------
Credential | D.M.D., M.S.
-----------------------------------------------------
Telephone | 505-982-5531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 1798
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------