Provider Demographics
NPI:1184751059
Name:HATHAWAY, KELLEY A (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:A
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KELLEY
Other - Middle Name:A
Other - Last Name:BEUCHAT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:4132 SE IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66609-1534
Mailing Address - Country:US
Mailing Address - Phone:785-266-5180
Mailing Address - Fax:
Practice Address - Street 1:5310 SW 37TH ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-4540
Practice Address - Country:US
Practice Address - Phone:785-267-5010
Practice Address - Fax:785-267-5010
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS64921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS116757OtherBLUE CROSS BLUE SHIELD