Provider Demographics
NPI:1437043858
Name:KELLY, PATRICK ANTHONY (DDS)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:ANTHONY
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 1:17 LOCKERBIE GRN
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-9276
Mailing Address - Country:US
Mailing Address - Phone:219-510-2506
Mailing Address - Fax:
Practice Address - Street 1:3801 S HURSTBOURNE PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-7319
Practice Address - Country:US
Practice Address - Phone:502-709-9430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY113721223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice