Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DN9377 | FL |
NPI | 1003416017 |
---|---|
Provider Name | Phillip Jeffery Kelemen |
First Address | Port Orange, FL 32127-8911 |
Second Address | Port Orange, FL 32127-8911 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2020 |
Last Update Date | 28/10/2020 |