Healthcare Provider Details

I. General information

NPI: 1811559396
Provider Name (Legal Business Name): GORDON ALEXANDER KELCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3739 MT BAKER HWY
EVERSON WA
98247-9406
US

IV. Provider business mailing address

3739 MT BAKER HWY
EVERSON WA
98247-9406
US

V. Phone/Fax

Practice location:
  • Phone: 360-592-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDENT.DE.61070148
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: