Healthcare Provider Details

I. General information

NPI: 1831423177
Provider Name (Legal Business Name): KELSEY PERIODONTAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17785 MASON ST SUITE 103
OMAHA NE
68118-3526
US

IV. Provider business mailing address

17785 MASON ST SUITE 103
OMAHA NE
68118-3526
US

V. Phone/Fax

Practice location:
  • Phone: 402-934-4745
  • Fax: 402-934-4760
Mailing address:
  • Phone: 402-934-4745
  • Fax: 402-934-4760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number6632
License Number StateNE

VIII. Authorized Official

Name: DR. WILLIAM PATRICK KELSEY V
Title or Position: OWNER
Credential: D.D.S., M.S.
Phone: 402-934-4745