Provider Demographics
NPI:1477210805
Name:EMMANS-ORT, KELLI LYN (RDH)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:LYN
Last Name:EMMANS-ORT
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 1:218 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-3137
Mailing Address - Country:US
Mailing Address - Phone:386-576-3780
Mailing Address - Fax:
Practice Address - Street 1:223 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-3392
Practice Address - Country:US
Practice Address - Phone:970-668-4043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DH002024634124Q00000X
CO124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10001110101Medicaid