Provider Demographics
NPI:1225871254
Name:KELLEY, ROBERT EV III (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EV
Last Name:KELLEY
Suffix:III
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SAINT JOHNS MEDICAL PARK DR STE C
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5202
Mailing Address - Country:US
Mailing Address - Phone:904-467-5507
Mailing Address - Fax:
Practice Address - Street 1:10 SAINT JOHNS MEDICAL PARK DR STE C
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5202
Practice Address - Country:US
Practice Address - Phone:904-467-5507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL263701223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics