Provider Demographics
NPI:1235764093
Name:RO, KELSEY (DMD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:RO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 REVERE BEACH PKWY APT 402
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5962
Mailing Address - Country:US
Mailing Address - Phone:818-395-2477
Mailing Address - Fax:
Practice Address - Street 1:78 NORTHEASTERN BLVD STE 5
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03062-3179
Practice Address - Country:US
Practice Address - Phone:603-883-6546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH04546122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist