David Randolph Kelly, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

0401006167 Issued in VA

Practice address

1941 Euclid Ave
Bristol, VA 24201-3607

Phone

(276) 669-0112

Fax

(276) 669-6922

NPI assigned

Jul 20, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153353600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1124048491",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1941 EUCLID AVE",
            "city": "BRISTOL",
            "state": "VA",
            "postal_code": "242013607",
            "telephone_number": "276-669-0112",
            "fax_number": "276-669-6922"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1941 EUCLID AVE",
            "city": "BRISTOL",
            "state": "VA",
            "postal_code": "242013607",
            "telephone_number": "276-669-0112",
            "fax_number": "276-669-6922"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KELLY",
        "first_name": "DAVID",
        "middle_name": "RANDOLPH",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-07-20",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "VA",
            "license": "0401006167",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "021225",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "0064919",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9178719",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• General Practice Dentistry in Bristol, VA
• Providers in Bristol, VA by specialty
• General Practice Dentistry in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.