Provider Demographics
NPI:1053563056
Name:KELSO, EMILY REBECCA (RDH)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:REBECCA
Last Name:KELSO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:REBECCA
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2690 NE KRESKY AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2412
Mailing Address - Country:US
Mailing Address - Phone:360-330-9595
Mailing Address - Fax:360-330-9580
Practice Address - Street 1:2690 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2412
Practice Address - Country:US
Practice Address - Phone:360-330-9595
Practice Address - Fax:360-330-9580
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH 60035140124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist