Individual
MARK T KELLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3637 NW 39TH ST, OKLAHOMA CITY, OK 73112-6309
(405) 942-7755
Mailing address
415 N GRAND AVE, PUEBLO, CO 81003-3111
(719) 546-3333
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
5869
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1888656
UNITED CONCORDIA
OK
05
—
200088150A
—
OK
Enumeration date
10/02/2006
Last updated
07/09/2007
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