Provider Demographics
NPI:1568873883
Name:BRATSBERG, KELLY JOE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JOE
Last Name:BRATSBERG
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 1:442 WEST HIGH STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506
Mailing Address - Country:US
Mailing Address - Phone:419-636-3163
Mailing Address - Fax:419-636-5037
Practice Address - Street 1:442 WEST HIGH STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506
Practice Address - Country:US
Practice Address - Phone:419-636-3163
Practice Address - Fax:419-636-5037
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300243881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice