Provider Demographics
NPI:1699061523
Name:KELLY, MATTHEW DIXON
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DIXON
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:D
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 1956
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1956
Mailing Address - Country:US
Mailing Address - Phone:928-645-3206
Mailing Address - Fax:928-645-9139
Practice Address - Street 1:112 SIXTH AVENUE
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-1956
Practice Address - Country:US
Practice Address - Phone:928-645-3206
Practice Address - Fax:928-645-9139
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008232122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist