Provider Demographics
NPI:1528411444
Name:CARLSON, KELLEY (DDS)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:CARLSON
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 1:2141 S 63RD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-2144
Mailing Address - Country:US
Mailing Address - Phone:402-551-1811
Mailing Address - Fax:
Practice Address - Street 1:2141 S 63RD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106
Practice Address - Country:US
Practice Address - Phone:402-551-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61343122300000X
OKRES-1326122300000X
NE7292122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK35-2382039Medicaid