Provider Demographics
NPI:1790322212
Name:MAXON, KILEY (LDH)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:
Last Name:MAXON
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:
Other - First Name:KILEY
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:57052 HIGHWAY 59
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:NE
Mailing Address - Zip Code:68745-1971
Mailing Address - Country:US
Mailing Address - Phone:402-841-3694
Mailing Address - Fax:
Practice Address - Street 1:215 N PEARL ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1975
Practice Address - Country:US
Practice Address - Phone:402-375-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2779124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist