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General NPI Number Information
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NPI Number | 1871979393
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Entity Type | Organization
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Legal Business Name | J. KELLY THEISEN, D.D.S.
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Dates
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Enumeration Date | 08/06/2015
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Last Update Date | 08/06/2015
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Provider Practice Location Address
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Address Line | 521 E RAILROAD AVENUE
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City | FORT MORGAN
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State | CO
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Zip | 80701-3331
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Country | US
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Telephone | 970-867-2256
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Fax | 970-542-9464
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Provider Business Mailing Address
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Address Line | 521 E RAILROAD AVENUE
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City | FORT MORGAN
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State | CO
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Zip | 80701-3331
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Country | US
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Telephone | 970-867-2256
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Fax | 970-542-9464
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Authorized Official
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Title or Position | OWNER
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Name | MR. JOHN KELLY THEISEN
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Credential | D.D.S.
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Telephone | 970-867-2256
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DEN00106339
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License Number State | CO
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