MEDICARE: DELAFIELD FAMILY DENTAL, INC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1831614627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELAFIELD FAMILY DENTAL, INC

Provider Business Mailing 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

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	:	OWNER/PRESIDENT
Name	:	DR. MICHELLE J KELLY
Credential	:	DDS
Telephone Number	:	262-646-4188

Provider Enumeration Date	:	08/14/2017
Last Update Date	:	07/21/2022

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