Provider Demographics
NPI:1609455781
Name:KELLEY, ABIGAIL (DMD)
Entity type:Individual
Prefix:DR
First Name:ABIGAIL
Middle Name:
Last Name:KELLEY
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9203 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6477
Mailing Address - Country:US
Mailing Address - Phone:440-255-3165
Mailing Address - Fax:
Practice Address - Street 1:35010 CHARDON RD STE 201
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-9011
Practice Address - Country:US
Practice Address - Phone:440-946-9701
Practice Address - Fax:440-946-9953
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN254971223G0001X
OH30.027081122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice