Provider Demographics
NPI:1366423527
Name:KELLEY, BRIAN PATRICK (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:PATRICK
Last Name:KELLEY
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:W230S4497 MILKY WAY ROAD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189
Mailing Address - Country:US
Mailing Address - Phone:262-312-8384
Mailing Address - Fax:
Practice Address - Street 1:W230S4497 MILKY WAY ROAD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189
Practice Address - Country:US
Practice Address - Phone:262-312-8384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5197-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI397627370000OtherBLUE CROSS/BLUE SHIELD
WIU95113Medicare UPIN