Provider Demographics
NPI:1669602405
Name:MCKELROY, JILLIAN K (DMD)
Entity type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:K
Last Name:MCKELROY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2048
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36652-2048
Mailing Address - Country:US
Mailing Address - Phone:251-432-4117
Mailing Address - Fax:251-964-4012
Practice Address - Street 1:1303 DR MARTIN L KING JR AVE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36603-5341
Practice Address - Country:US
Practice Address - Phone:251-432-4117
Practice Address - Fax:251-964-4012
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5672122300000X, 1223G0001X, 1223P0106X, 1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No1223P0221XDental ProvidersDentistPediatric Dentistry
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5672OtherALABAMA STATE LICENSE