Provider Demographics
NPI:1891179966
Name:JOHNSON, KELSEY DIANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:DIANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 535
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-0535
Mailing Address - Country:US
Mailing Address - Phone:270-274-5121
Mailing Address - Fax:270-274-5122
Practice Address - Street 1:1317 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-8957
Practice Address - Country:US
Practice Address - Phone:270-274-5121
Practice Address - Fax:270-274-5122
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9595122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice