Provider Demographics
NPI:1154638187
Name:KELSO, ANDREW BRANDON (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:BRANDON
Last Name:KELSO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2465 LAUREL GLEN DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-5406
Mailing Address - Country:US
Mailing Address - Phone:954-579-0289
Mailing Address - Fax:
Practice Address - Street 1:330 E HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813
Practice Address - Country:US
Practice Address - Phone:863-644-0430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 19117122300000X
FLDN191171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No122300000XDental ProvidersDentist