Provider Demographics
NPI:1538387154
Name:KELLEY, RANDALL JAMES (DMD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:JAMES
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9255 MAISON DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-2427
Mailing Address - Country:US
Mailing Address - Phone:650-218-0069
Mailing Address - Fax:801-375-3598
Practice Address - Street 1:275 N 500 W
Practice Address - Street 2:SUITE C
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-3006
Practice Address - Country:US
Practice Address - Phone:801-374-5768
Practice Address - Fax:801-375-3598
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA330521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice