Provider Demographics
NPI:1356681407
Name:KELSON, MICHAEL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:KELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3624 ENSIGN RD NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5074
Mailing Address - Country:US
Mailing Address - Phone:360-923-5412
Mailing Address - Fax:360-923-5382
Practice Address - Street 1:3624 ENSIGN RD NE
Practice Address - Street 2:SUITE A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5074
Practice Address - Country:US
Practice Address - Phone:360-923-5412
Practice Address - Fax:360-923-5382
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA71001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery