MEDICARE: KEVIN CHARLES KELLY D.D.S.

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	1223G0001X	General Practice Dentistry	12127	MI

General Provider Information

NPI Number	:	1225123904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN CHARLES KELLY D.D.S.

Provider Business Mailing Address
First Line	:	555 S GARFIELD AVE
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-3423
Country	:	US
Telephone Number	:	231-947-0210
Fax Number	:	231-947-6770

Provider Business Practice Location Address
First Line	:	555 S GARFIELD AVE
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-3423
Country	:	US
Telephone Number	:	231-947-0210
Fax Number	:	231-947-6770

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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