Provider Demographics
NPI:1932525136
Name:MENEGOTTO, KELSEY DENISE (DMD)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:DENISE
Last Name:MENEGOTTO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:KELSEY
Other - Middle Name:DENISE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10972 ALLISONVILLE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2639
Mailing Address - Country:US
Mailing Address - Phone:270-314-6363
Mailing Address - Fax:317-913-2360
Practice Address - Street 1:777 BEACHWAY DR STE 202
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-7877
Practice Address - Country:US
Practice Address - Phone:317-297-1007
Practice Address - Fax:317-405-8694
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9892122300000X, 204E00000X
IN12013532A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty