Provider Demographics
NPI:1417497389
Name:KELSON, STEPHEN MATHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MATHEW
Last Name:KELSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 NORTH STATE STREET,
Mailing Address - Street 2:LAC USC MEDICAL CENTER CT-A7D
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 NORTH STATE STREET,
Practice Address - Street 2:LAC USC MEDICAL CENTER CT-A7D
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:360-515-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program