Provider Demographics
NPI:1871621854
Name:EASTGLEN DENTAL ASSOCIATES SCOTT KELLY DDS LLC
Entity type:Organization
Organization Name:EASTGLEN DENTAL ASSOCIATES SCOTT KELLY DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-491-5511
Mailing Address - Street 1:6465 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1576
Mailing Address - Country:US
Mailing Address - Phone:614-868-0808
Mailing Address - Fax:
Practice Address - Street 1:6465 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1576
Practice Address - Country:US
Practice Address - Phone:614-868-0808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty