MEDICARE: DR. THOMAS VINCENT KELLY JR. DDS

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	4720	NC

General Provider Information

NPI Number	:	1275536914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS VINCENT KELLY JR. DDS

Provider Business Mailing Address
First Line	:	9317 LEESVILLE RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27613-7515
Country	:	US
Telephone Number	:	919-848-1343
Fax Number	:	919-848-9418

Provider Business Practice Location Address
First Line	:	9317 LEESVILLE RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27613-7515
Country	:	US
Telephone Number	:	919-848-1343
Fax Number	:	919-848-9418

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

Provider Enumeration Date	:	05/26/2005
Last Update Date	:	07/08/2007

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