MEDICARE: MACKENZIE KELLEY 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	122300000X	Dentist	DS041272	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	99455663	OTHER	IN	DENTPIN

General Provider Information

NPI Number	:	1356703847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE KELLEY DDS

Provider Business Mailing Address
First Line	:	1809 JANCEY ST
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15206-1065
Country	:	US
Telephone Number	:	412-362-5677
Fax Number	:	412-362-0742

Provider Business Practice Location Address
First Line	:	1809 JANCEY ST
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15206-1065
Country	:	US
Telephone Number	:	412-362-5677
Fax Number	:	412-362-0742

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

Provider Enumeration Date	:	03/23/2016
Last Update Date	:	07/21/2022

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Directions to “ MACKENZIE KELLEY DDS” Practice Location

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