Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | D11639 | MN |
NPI | 1063584563 |
---|---|
Provider Name | Dr. Jess Andrew Kelly |
First Address | North Mankato, MN 56003-1431 |
Second Address | Mankato, MN 56001-5192 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2006 |
Last Update Date | 08/07/2007 |