Provider Demographics
NPI:1346818374
Name:CALLAHAN, KELSI M (RDH)
Entity Type:Individual
Prefix:
First Name:KELSI
Middle Name:M
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:KELSI
Other - Middle Name:M
Other - Last Name:HAYDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:9741 SMOKE WAGON DR
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89441-9267
Mailing Address - Country:US
Mailing Address - Phone:775-721-2174
Mailing Address - Fax:
Practice Address - Street 1:601 W MOANA LN STE 1
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4949
Practice Address - Country:US
Practice Address - Phone:775-543-2522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101121124Q00000X, 225500000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No124Q00000XDental ProvidersDental Hygienist
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Single Specialty