Provider Demographics
NPI:1649828906
Name:LUSSETTO, KATIE JEAN
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:JEAN
Last Name:LUSSETTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 SIOUX LN
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6754
Mailing Address - Country:US
Mailing Address - Phone:308-340-8182
Mailing Address - Fax:
Practice Address - Street 1:321 E 3RD ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-4032
Practice Address - Country:US
Practice Address - Phone:308-534-1332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2071124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist