Provider Demographics
NPI:1366724023
Name:KELLEY, CONNOR FITZPATRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:CONNOR
Middle Name:FITZPATRICK
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 1:1100 RAYFORD RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-1561
Mailing Address - Country:US
Mailing Address - Phone:281-602-8843
Mailing Address - Fax:
Practice Address - Street 1:1100 RAYFORD RD
Practice Address - Street 2:STE. 100
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-1561
Practice Address - Country:US
Practice Address - Phone:281-602-8843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX274041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX671835Medicare Oscar/Certification
TX080462703Medicaid