1750762282 NPI number — WAYNE G KELLY DDS PC

Table of content: (NPI 1750762282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750762282 NPI number — WAYNE G KELLY DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNE G KELLY DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750762282
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
342 BEACH 54TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARVERNE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11692-1782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
342 BEACH 54TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARVERNE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11692-1782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-474-0801
Provider Business Practice Location Address Fax Number:
718-318-2247
Provider Enumeration Date:
06/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
718-474-0801

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  037615 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00778267 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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