Provider Demographics
NPI:1386441541
Name:SAMUEL R KELLY DMD LLC
Entity type:Organization
Organization Name:SAMUEL R KELLY DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-991-8897
Mailing Address - Street 1:3380 ASTORIA WAY NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1667
Mailing Address - Country:US
Mailing Address - Phone:503-588-7800
Mailing Address - Fax:
Practice Address - Street 1:3380 ASTORIA WAY NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1667
Practice Address - Country:US
Practice Address - Phone:503-588-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty