Provider Demographics
NPI:1326200072
Name:KELSEY, MATTHEW RYAN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
Last Name:KELSEY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17785 MASON ST
Mailing Address - Street 2:#103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-3526
Mailing Address - Country:US
Mailing Address - Phone:402-934-4745
Mailing Address - Fax:402-934-4760
Practice Address - Street 1:17785 MASON ST
Practice Address - Street 2:#103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-3526
Practice Address - Country:US
Practice Address - Phone:402-934-4745
Practice Address - Fax:402-934-4760
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE67511223P0300X
MND12556390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223P0300XDental ProvidersDentistPeriodontics