Provider Demographics
NPI:1205320439
Name:HANSEN, KELLIE (DMD)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:HANSEN
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 1:38224 S DARNELL RD
Mailing Address - Street 2:
Mailing Address - City:WELLFLEET
Mailing Address - State:NE
Mailing Address - Zip Code:69170-7064
Mailing Address - Country:US
Mailing Address - Phone:308-362-4356
Mailing Address - Fax:
Practice Address - Street 1:221 S JEFFERS ST STE 1
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5371
Practice Address - Country:US
Practice Address - Phone:308-534-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE74821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice