Healthcare Provider Details

I. General information

NPI: 1306410501
Provider Name (Legal Business Name): KELSEY MARIE GWIN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S WOODLAND ST
WINTER GARDEN FL
34787-3546
US

IV. Provider business mailing address

15820 DORA AVE STE A
TAVARES FL
32778-4969
US

V. Phone/Fax

Practice location:
  • Phone: 407-905-8827
  • Fax: 407-905-8998
Mailing address:
  • Phone: 352-589-5660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN26405
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: