Provider Demographics
NPI:1841573201
Name:CONWAY, KELLY RICHARD (DDS, MS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RICHARD
Last Name:CONWAY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 N 87TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2801
Mailing Address - Country:US
Mailing Address - Phone:402-393-2300
Mailing Address - Fax:402-393-4700
Practice Address - Street 1:535 N 87TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2801
Practice Address - Country:US
Practice Address - Phone:402-393-2300
Practice Address - Fax:402-393-4700
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE52781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics