Provider Demographics
NPI:1255995163
Name:DELAET, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DELAET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E 52ND ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-8506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3810 A AVE STE D
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-8171
Practice Address - Country:US
Practice Address - Phone:308-234-9037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7530122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program