Provider Demographics
NPI:1285979625
Name:KELLY, JILL ALLISON (IPDH)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:ALLISON
Last Name:KELLY
Suffix:
Gender:F
Credentials:IPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 48
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:ME
Mailing Address - Zip Code:04001-0048
Mailing Address - Country:US
Mailing Address - Phone:207-604-9027
Mailing Address - Fax:
Practice Address - Street 1:1881 RT. 109
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:ME
Practice Address - Zip Code:04001
Practice Address - Country:US
Practice Address - Phone:207-604-9027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME52124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist