Provider Demographics
NPI:1629076989
Name:THEISEN, JOHN KELLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KELLY
Last Name:THEISEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 E RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-3331
Mailing Address - Country:US
Mailing Address - Phone:970-867-2256
Mailing Address - Fax:970-542-9464
Practice Address - Street 1:521 E RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3331
Practice Address - Country:US
Practice Address - Phone:970-867-2256
Practice Address - Fax:970-542-9464
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist