Provider Demographics
NPI:1558254433
Name:KELLY ROAD DENTISTRY PLLC
Entity type:Organization
Organization Name:KELLY ROAD DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WASSIM
Authorized Official - Middle Name:
Authorized Official - Last Name:EL AWADI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-377-0264
Mailing Address - Street 1:460 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1573
Mailing Address - Country:US
Mailing Address - Phone:734-377-0264
Mailing Address - Fax:
Practice Address - Street 1:25810 KELLY RD STE 2
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4467
Practice Address - Country:US
Practice Address - Phone:586-775-4260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental