Provider Demographics
NPI:1689710873
Name:KAELIN, DEREK RYAN (DDS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:RYAN
Last Name:KAELIN
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 1:2105 W. KEARNEY
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803
Mailing Address - Country:US
Mailing Address - Phone:417-862-2468
Mailing Address - Fax:417-863-6775
Practice Address - Street 1:540 W LASALLE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4712
Practice Address - Country:US
Practice Address - Phone:417-887-1220
Practice Address - Fax:417-887-0357
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODEN 20030171251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice