Provider Demographics
NPI:1093916025
Name:BERTELSEN, KELLY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:BERTELSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9598 PROTOTYPE CT
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-5916
Mailing Address - Country:US
Mailing Address - Phone:775-852-8181
Mailing Address - Fax:775-852-8199
Practice Address - Street 1:9598 PROTOTYPE CT
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-5916
Practice Address - Country:US
Practice Address - Phone:775-852-8181
Practice Address - Fax:775-852-8199
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV50491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice