Provider Demographics
NPI:1447821319
Name:JACOB D KELLY DDS, INC.
Entity type:Organization
Organization Name:JACOB D KELLY DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-782-9479
Mailing Address - Street 1:2360 PROFESSIONAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-7782
Mailing Address - Country:US
Mailing Address - Phone:916-782-9479
Mailing Address - Fax:916-782-3342
Practice Address - Street 1:2360 PROFESSIONAL DR STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7782
Practice Address - Country:US
Practice Address - Phone:916-782-9479
Practice Address - Fax:916-782-3342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental