Provider Demographics
NPI:1215147079
Name:KELLY, THOMAS STEWART (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:STEWART
Last Name:KELLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 PARK EAST DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4339
Mailing Address - Country:US
Mailing Address - Phone:216-464-3777
Mailing Address - Fax:216-464-3377
Practice Address - Street 1:3700 PARK EAST DR
Practice Address - Street 2:SUITE 180
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4339
Practice Address - Country:US
Practice Address - Phone:216-464-3777
Practice Address - Fax:216-464-3377
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-98091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice