Provider Demographics
NPI:1356432413
Name:KELLY, ROY WILLIAM III (DDS)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:WILLIAM
Last Name:KELLY
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3529 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-6664
Mailing Address - Country:US
Mailing Address - Phone:704-860-1328
Mailing Address - Fax:
Practice Address - Street 1:1725 S NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5850
Practice Address - Country:US
Practice Address - Phone:704-867-1671
Practice Address - Fax:704-867-0533
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC77791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
94825OtherBCBS
T63922Medicare UPIN