Provider Demographics
NPI:1245259209
Name:LINEBACK, KELLY MITCHELL (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MITCHELL
Last Name:LINEBACK
Suffix:
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 1:407 CLAIRBORNE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062
Mailing Address - Country:US
Mailing Address - Phone:913-782-8838
Mailing Address - Fax:913-782-6776
Practice Address - Street 1:407 CLAIRBORNE
Practice Address - Street 2:SUITE 200
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062
Practice Address - Country:US
Practice Address - Phone:913-782-8838
Practice Address - Fax:913-782-6776
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6568122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist