Provider Demographics
NPI:1528233772
Name:KELLY ORTHODONTICS, PC
Entity type:Organization
Organization Name:KELLY ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:845-357-0200
Mailing Address - Street 1:79 ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901
Mailing Address - Country:US
Mailing Address - Phone:845-357-0200
Mailing Address - Fax:845-357-0253
Practice Address - Street 1:79 ROUTE 59
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901
Practice Address - Country:US
Practice Address - Phone:845-357-0200
Practice Address - Fax:845-357-0253
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KELLY ORTHODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-29
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05161911223X0400X, 1223X0400X
NY0478011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty