Healthcare Provider Details

I. General information

NPI: 1417497389
Provider Name (Legal Business Name): STEPHEN MATHEW KELSON D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 ENSIGN RD NE STE A
OLYMPIA WA
98506-5074
US

IV. Provider business mailing address

3624 ENSIGN RD NE STE A
OLYMPIA WA
98506-5074
US

V. Phone/Fax

Practice location:
  • Phone: 360-923-5412
  • Fax:
Mailing address:
  • Phone: 360-923-5412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDE61354113
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: