MEDICARE: EASTGLEN DENTAL ASSOCIATES SCOTT KELLY DDS LLC

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

General Provider Information

NPI Number	:	1871621854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTGLEN DENTAL ASSOCIATES SCOTT KELLY DDS LLC

Provider Business Mailing Address
First Line	:	6465 E BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1576
Country	:	US
Telephone Number	:	614-868-0808
Fax Number	:

Provider Business Practice Location Address
First Line	:	6465 E BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1576
Country	:	US
Telephone Number	:	614-868-0808
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	SCOTT KELLY
Credential	:
Telephone Number	:	614-491-5511

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	08/22/2020

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