Provider Demographics
NPI:1255527016
Name:MATHESON, KELLY (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MATHESON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3801 FAIRFAX DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1762
Mailing Address - Country:US
Mailing Address - Phone:703-527-3554
Mailing Address - Fax:
Practice Address - Street 1:475 KEENE RD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-5007
Practice Address - Country:US
Practice Address - Phone:509-627-6888
Practice Address - Fax:509-627-6720
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010940122300000X
VA0401412425122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist