Provider Demographics
NPI:1356879688
Name:ATEN, KELLY RENEE (DMD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:RENEE
Last Name:ATEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RENEE
Other - Last Name:KOSTELNIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2620 W WALL ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-3301
Mailing Address - Country:US
Mailing Address - Phone:608-405-8345
Mailing Address - Fax:
Practice Address - Street 1:113 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3812
Practice Address - Country:US
Practice Address - Phone:608-756-4638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002231-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist