Provider Demographics
NPI:1356667018
Name:KAVAN, KELLI LYNNE (RDH)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNNE
Last Name:KAVAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6444 N 149TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-4587
Mailing Address - Country:US
Mailing Address - Phone:402-699-5789
Mailing Address - Fax:
Practice Address - Street 1:6444 N 149TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-4587
Practice Address - Country:US
Practice Address - Phone:402-699-5789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1501124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist