Provider Demographics
NPI:1174819841
Name:OPHUS, KELLIE SUE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:SUE
Last Name:OPHUS
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 1:208 N CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-3411
Mailing Address - Country:US
Mailing Address - Phone:405-830-6437
Mailing Address - Fax:
Practice Address - Street 1:19 W INTERSTATE PKWY
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1331
Practice Address - Country:US
Practice Address - Phone:405-275-0675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK62921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice