Provider Demographics
NPI:1366952814
Name:KEALLY DENTISTRY, PLLC
Entity type:Organization
Organization Name:KEALLY DENTISTRY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARSON
Authorized Official - Middle Name:P
Authorized Official - Last Name:KEALLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-744-0200
Mailing Address - Street 1:140 HUBBARD RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-2412
Mailing Address - Country:US
Mailing Address - Phone:859-744-0200
Mailing Address - Fax:859-744-0220
Practice Address - Street 1:140 HUBBARD RD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-2412
Practice Address - Country:US
Practice Address - Phone:859-744-0200
Practice Address - Fax:859-744-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty