Provider Demographics
NPI:1689346652
Name:MITCHELL, KELLEY (CDH)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:CDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7119 W 72ND ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204-1936
Mailing Address - Country:US
Mailing Address - Phone:310-363-0720
Mailing Address - Fax:
Practice Address - Street 1:11644 W 75TH ST STE 101
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66214-1300
Practice Address - Country:US
Practice Address - Phone:913-962-0036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12702124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS12702OtherKANSAS DENTAL BOARD