MEDICARE: JOHN M KELLEY JR. JOHN KELLEY, DDS, MS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	TX19132	TX

General Provider Information

NPI Number	:	1437378965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN M KELLEY JR. JOHN KELLEY, DDS, MS

Provider Business Mailing Address
First Line	:	1533 MERRIMAC CIR
Second Line	:	SUITE 207
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6571
Country	:	US
Telephone Number	:	817-338-0771
Fax Number	:	817-332-8072

Provider Business Practice Location Address
First Line	:	1533 MERRIMAC CIR
Second Line	:	SUITE 207
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6571
Country	:	US
Telephone Number	:	817-338-0771
Fax Number	:	817-332-8072

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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