MEDICARE: DR. KELSEY CHILDERS-EDE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	30.024837	OH

General Provider Information

NPI Number	:	1215388012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELSEY CHILDERS-EDE DMD

Provider Business Mailing Address
First Line	:	129 EASTON ST NE
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44721-2488
Country	:	US
Telephone Number	:	330-494-3400
Fax Number	:

Provider Business Practice Location Address
First Line	:	129 EASTON ST NE STE 101
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44721-2488
Country	:	US
Telephone Number	:	330-494-3400
Fax Number	:	330-680-5501

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2016
Last Update Date	:	12/17/2023

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