Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 008783 | CT |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 038903 | CT |
NPI | 1386685022 |
---|---|
Provider Name | Dr. John Patrick Washington Kelly |
First Address | New Haven, CT 06511-4405 |
Second Address | New Haven, CT 06511-4405 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2006 |
Last Update Date | 12/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D85825 | (02) | CT |