Basic Information
| Provider Information | |||||||||
| NPI: | 1659931301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOONTJER | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4321 41ST AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 686012131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025639224 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4321 41ST AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 686012131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025628954 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2019 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D11044 | OR | Y | Dental Providers | Dentist |
No ID Information.