Active NPI
Jerry C. Kelly, DDS
- Dentist
- Marshall, MO
National Provider Identifier
1386853745
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 12712
- Practice address
- 263 S Jefferson Ave
Marshall, MO 65340-2134 - Phone
- (660) 886-6843
- Fax
- (660) 886-7855
- NPI assigned
- May 22, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 12712 | MO | Primary |
Addresses
Primary practice location
263 S Jefferson Ave
Marshall, MO 65340-2134
Mailing address
263 S Jefferson Ave
Marshall, MO 65340-2134
Phone (660) 886-6843
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 12712 | Other | MO | STATE LICENSE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12712 | MO | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Marshall Dental Care, LLC | Past | Accepting new patients | |
| Wright Dental LLC | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Dental Clinic/Center
- Marshall, MO
- NPI 1962918425
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1179792000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1386853745",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "263 S JEFFERSON AVE",
"city": "MARSHALL",
"state": "MO",
"postal_code": "653402134",
"telephone_number": "660-886-6843",
"fax_number": "660-886-7855"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "263 S JEFFERSON AVE",
"city": "MARSHALL",
"state": "MO",
"postal_code": "653402134",
"telephone_number": "660-886-6843",
"fax_number": "660-886-7855"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KELLY",
"first_name": "JERRY",
"middle_name": "C.",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-05-22",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MO",
"license": "12712",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE LICENSE",
"identifier": "12712",
"state": "MO"
}
],
"endpoints": [],
"other_names": []
}Other providers in Marshall, MO
Sources for this page
- 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.