MEDICARE: DR. MICHELLE J 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	5721-015	WI

General Provider Information

NPI Number	:	1245215920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE J KELLY D.D.S.

Provider Business Mailing Address
First Line	:	36032 RAVINIA PARK BLVD
Second Line	:
City	:	OCONOMOWOC
State	:	WI
Zip	:	53066-6714
Country	:	US
Telephone Number	:	414-975-7190
Fax Number	:	262-646-4181

Provider Business Practice Location Address
First Line	:	11 CROSSROADS CT
Second Line	:
City	:	DELAFIELD
State	:	WI
Zip	:	53018-2035
Country	:	US
Telephone Number	:	262-646-4188
Fax Number	:	262-646-4181

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

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	07/21/2022

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