Provider Demographics
NPI:1588764435
Name:KURTIS S KELLNER DDS SC
Entity type:Organization
Organization Name:KURTIS S KELLNER DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KURTIS
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:KELLNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-457-5170
Mailing Address - Street 1:1931 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081
Mailing Address - Country:US
Mailing Address - Phone:920-457-5170
Mailing Address - Fax:920-457-2450
Practice Address - Street 1:1931 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-457-5170
Practice Address - Fax:920-457-2450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00029491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty