Provider Demographics
NPI:1215920632
Name:FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-642-2111
Mailing Address - Street 1:89 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12832-1138
Mailing Address - Country:US
Mailing Address - Phone:518-642-2111
Mailing Address - Fax:518-642-2891
Practice Address - Street 1:89 NORTH ST
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:NY
Practice Address - Zip Code:12832-1138
Practice Address - Country:US
Practice Address - Phone:518-642-2111
Practice Address - Fax:518-642-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010081Medicaid
NY02375744Medicaid