Provider Demographics
NPI:1356567333
Name:KELSTROM, LYLE DUANE (DDS)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:DUANE
Last Name:KELSTROM
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6202 NE HIGHWAY 99
Mailing Address - Street 2:#5
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8747
Mailing Address - Country:US
Mailing Address - Phone:360-693-2592
Mailing Address - Fax:360-750-7939
Practice Address - Street 1:6202 NE HIGHWAY 99
Practice Address - Street 2:#5
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8747
Practice Address - Country:US
Practice Address - Phone:360-693-2592
Practice Address - Fax:360-750-7939
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00004874122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist