Provider Demographics
NPI:1023343803
Name:KELLY B DEETER, DDS, CHTD
Entity type:Organization
Organization Name:KELLY B DEETER, DDS, CHTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:B
Authorized Official - Last Name:DEETER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:785-267-6120
Mailing Address - Street 1:2300 SW 29TH
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66611-1887
Mailing Address - Country:US
Mailing Address - Phone:785-267-6120
Mailing Address - Fax:785-267-6928
Practice Address - Street 1:2300 SW 29TH
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66611-1887
Practice Address - Country:US
Practice Address - Phone:785-267-6120
Practice Address - Fax:785-267-6928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1841291846OtherNPI TYPE 1
KS4522OtherSTATE LISENCE