Provider Demographics
NPI:1154589307
Name:KELSEY, JOHN HENRY (DDS, MS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HENRY
Last Name:KELSEY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CENTRE CT
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-4105
Mailing Address - Country:US
Mailing Address - Phone:847-334-4050
Mailing Address - Fax:
Practice Address - Street 1:534 W 19TH ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2748
Practice Address - Country:US
Practice Address - Phone:714-571-3392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA627841223X0400X
IL0210018051223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics