Provider Demographics
NPI:1962492678
Name:KELSEY, MARY NAN IV (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:NAN
Last Name:KELSEY
Suffix:IV
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 1:220 N 89TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4072
Mailing Address - Country:US
Mailing Address - Phone:402-390-6006
Mailing Address - Fax:402-390-6446
Practice Address - Street 1:220 N 89TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4072
Practice Address - Country:US
Practice Address - Phone:402-390-6006
Practice Address - Fax:402-390-6446
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE46751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice