Provider Demographics
NPI:1053513531
Name:KELLEHER, ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:KELLEHER
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 1:13385 FOLSOM BLVD
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-8004
Mailing Address - Country:US
Mailing Address - Phone:916-985-8420
Mailing Address - Fax:916-985-6109
Practice Address - Street 1:13385 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-8004
Practice Address - Country:US
Practice Address - Phone:916-985-8420
Practice Address - Fax:916-985-6109
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAJ 287361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics