Provider Demographics
NPI:1740745728
Name:DIERIKX, KELSEY (DDS)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:
Last Name:DIERIKX
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 1:322 DENTAL SCIENCE BLDG S
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1001
Mailing Address - Country:US
Mailing Address - Phone:319-335-7440
Mailing Address - Fax:319-335-7451
Practice Address - Street 1:2814 NORTHGATE DR STE 2
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-9505
Practice Address - Country:US
Practice Address - Phone:319-335-5484
Practice Address - Fax:319-338-9413
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09677122300000X, 1223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program