Provider Demographics
NPI:1285882977
Name:KELLY, RUSSELL A (DDS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:A
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 1:951 N TUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-5902
Mailing Address - Country:US
Mailing Address - Phone:714-532-3331
Mailing Address - Fax:714-532-5886
Practice Address - Street 1:951 N TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5902
Practice Address - Country:US
Practice Address - Phone:714-532-3331
Practice Address - Fax:714-532-5886
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43284122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist