Provider Demographics
NPI:1053312363
Name:KELLOW, HIBA A (DDS)
Entity Type:Individual
Prefix:DR
First Name:HIBA
Middle Name:A
Last Name:KELLOW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:HIBA
Other - Middle Name:A
Other - Last Name:KELLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:5305 S 96TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-3317
Mailing Address - Country:US
Mailing Address - Phone:402-331-0701
Mailing Address - Fax:
Practice Address - Street 1:5305 S 96TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-3317
Practice Address - Country:US
Practice Address - Phone:402-331-0701
Practice Address - Fax:402-331-7130
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86391223G0001X
NE7118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04010443Medicaid