Provider Demographics
NPI:1992122832
Name:KELLY, JOSEPH THOMAS (DDS)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:THOMAS
Last Name:KELLY
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 1:1480 W ASHLEY RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-2141
Mailing Address - Country:US
Mailing Address - Phone:660-882-7522
Mailing Address - Fax:660-882-9022
Practice Address - Street 1:1480 W ASHLEY RD
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-2141
Practice Address - Country:US
Practice Address - Phone:660-882-7522
Practice Address - Fax:660-882-9022
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8345122300000X
MO2014008013122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist