Provider Demographics
NPI:1467020362
Name:DISKIN, KELSIE LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:KELSIE
Middle Name:LYNN
Last Name:DISKIN
Suffix:
Gender:
Credentials:DDS
Other - Prefix:DR
Other - First Name:KELSIE
Other - Middle Name:LYNN
Other - Last Name:JACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:360 HERITAGE WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002
Mailing Address - Country:US
Mailing Address - Phone:316-733-4886
Mailing Address - Fax:316-733-8476
Practice Address - Street 1:360 HERITAGE WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002
Practice Address - Country:US
Practice Address - Phone:316-733-4886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61874122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist