Basic Information
| Provider Information | |||||||||
| NPI: | 1730417254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELSO | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | MAYRUS | ||||||||
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| Credential: | DENTAL HYGENTIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 N IRON BRIDGE WAY | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992024932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448888 | ||||||||
| FaxNumber: | 5094447806 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DEER PARK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990068238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448200 | ||||||||
| FaxNumber: | 5094447806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH60119564 | WA | Y | Dental Providers | Dental Hygienist |
No ID Information.