Provider Demographics
NPI:1407164502
Name:KELSO, SHANNON HOLER (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:HOLER
Last Name:KELSO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:FRANCES
Other - Last Name:HOLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2156 HARDEN BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803
Mailing Address - Country:US
Mailing Address - Phone:863-603-7400
Mailing Address - Fax:863-603-7411
Practice Address - Street 1:2156 HARDEN BLVD.
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803
Practice Address - Country:US
Practice Address - Phone:863-603-7400
Practice Address - Fax:863-603-7411
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59793122300000X
FLDN209191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist