Provider Demographics
NPI:1316324031
Name:PAUL KELLY MAXILLOFACIAL PC
Entity type:Organization
Organization Name:PAUL KELLY MAXILLOFACIAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:480-258-0879
Mailing Address - Street 1:726 N GREENFIELD RD
Mailing Address - Street 2:SUITE #117
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-5061
Mailing Address - Country:US
Mailing Address - Phone:480-258-0879
Mailing Address - Fax:
Practice Address - Street 1:726 N GREENFIELD RD
Practice Address - Street 2:SUITE #117
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-5061
Practice Address - Country:US
Practice Address - Phone:480-258-0879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD69131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty