Provider Demographics
NPI:1053354258
Name:KELLY, KRISTOPHER JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTOPHER
Middle Name:JOHN
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 1:1000 HEALTH CENTER ROAD
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:SD
Mailing Address - Zip Code:57752-0540
Mailing Address - Country:US
Mailing Address - Phone:605-455-8025
Mailing Address - Fax:605-455-1529
Practice Address - Street 1:1000 HEALTH CENTER ROAD
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:SD
Practice Address - Zip Code:57752-0540
Practice Address - Country:US
Practice Address - Phone:605-455-8025
Practice Address - Fax:605-455-1529
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA64841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice