MEDICARE: DR. ELIZABETH KELLNER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	D11686	OR
2	1223P0221X	Pediatric Dentistry	073	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760521934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH KELLNER DDS

Provider Business Mailing Address
First Line	:	PO BOX 7861
Second Line	:
City	:	MOORE
State	:	OK
Zip	:	73153-1861
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2468 TREMONT ST
Second Line	:
City	:	NORTH BEND
State	:	OR
Zip	:	97459-3320
Country	:	US
Telephone Number	:	541-756-0156
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	11/09/2022

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