Provider Demographics
NPI:1871338954
Name:KELLEY, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38994 DUSTY LN
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-8773
Mailing Address - Country:US
Mailing Address - Phone:406-883-6247
Mailing Address - Fax:
Practice Address - Street 1:38994 DUSTY LN
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-8773
Practice Address - Country:US
Practice Address - Phone:406-883-6247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126900000XDental ProvidersDental Laboratory Technician