MEDICARE: KELSEY & JO ORTHODONTICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	060006833	IL

General Provider Information

NPI Number	:	1053579219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELSEY & JO ORTHODONTICS

Provider Business Mailing Address
First Line	:	332 SKOKIE VALLEY RD
Second Line	:	SUITE # 222
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-4415
Country	:	US
Telephone Number	:	847-831-1100
Fax Number	:

Provider Business Practice Location Address
First Line	:	332 SKOKIE VALLEY RD
Second Line	:	SUITE # 222
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-4415
Country	:	US
Telephone Number	:	847-831-1100
Fax Number	:

Authorized Official
Title or Position	:	PRESEIDENT
Name	:	JOHN HENRY KELSEY
Credential	:	D.D.S., M.S.
Telephone Number	:	847-831-1100

Provider Enumeration Date	:	05/23/2008
Last Update Date	:	05/23/2008

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