Provider Demographics
NPI:1316730153
Name:COLE, KELLEY JANE (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:JANE
Last Name:COLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22201 MOROSS RD STE 155
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2152
Mailing Address - Country:US
Mailing Address - Phone:313-499-4775
Mailing Address - Fax:313-499-4953
Practice Address - Street 1:5716 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-3039
Practice Address - Country:US
Practice Address - Phone:313-554-3880
Practice Address - Fax:313-228-0283
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-24
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301094326122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program