MEDICARE: BRIAN PATRICK 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	5197-015	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	397627370000	OTHER	WI	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1366423527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN PATRICK KELLEY DDS

Provider Business Mailing Address
First Line	:	W230S4497 MILKY WAY ROAD
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53189
Country	:	US
Telephone Number	:	262-312-8384
Fax Number	:

Provider Business Practice Location Address
First Line	:	W230S4497 MILKY WAY ROAD
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53189
Country	:	US
Telephone Number	:	262-312-8384
Fax Number	:

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

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	02/21/2025

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