Provider Demographics
NPI:1447254966
Name:KELLEY, JUSTINE R (DMD)
Entity type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:R
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:R
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:4 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-2578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1540 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2215
Practice Address - Country:US
Practice Address - Phone:617-738-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice