Provider Demographics
NPI:1730244732
Name:KELLEY, JEFFREY OLIN (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:OLIN
Last Name:KELLEY
Suffix:
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 1:25 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1210
Mailing Address - Country:US
Mailing Address - Phone:616-772-2868
Mailing Address - Fax:616-772-4805
Practice Address - Street 1:25 N STATE ST
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1210
Practice Address - Country:US
Practice Address - Phone:616-772-2868
Practice Address - Fax:616-772-4805
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010190601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice