Provider Demographics
NPI:1558111088
Name:DEBERG, KAILEY JEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:KAILEY
Middle Name:JEAN
Last Name:DEBERG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KAILEY
Other - Middle Name:
Other - Last Name:SIEMONSMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1705 E PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-882-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024018750122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist