Provider Demographics
NPI:1295403749
Name:SMITH, KELSEY KATHRYN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:KATHRYN
Last Name:SMITH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 ISLAND AVE APT 1807
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-8014
Mailing Address - Country:US
Mailing Address - Phone:360-789-9414
Mailing Address - Fax:
Practice Address - Street 1:3230 BRANCH DENTAL CLINIC
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:92136
Practice Address - Country:US
Practice Address - Phone:619-556-8240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61189774122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist