Provider Demographics
NPI:1366153470
Name:KELLEY, CONNOR (DMD, MS)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SHANE DR
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661
Mailing Address - Country:US
Mailing Address - Phone:334-718-5246
Mailing Address - Fax:
Practice Address - Street 1:1708 FIRESTONE AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-1974
Practice Address - Country:US
Practice Address - Phone:256-814-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0006994-C11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics