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General NPI Number Information
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NPI Number | 1063933950
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Entity Type | Individual
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Provider Name | SAMUEL JOHN KELCH DDS
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Gender | Male
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Dates
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Enumeration Date | 06/29/2017
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Last Update Date | 06/29/2017
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Provider Practice Location Address
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Address Line | 1414 BLIZZARD DR
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City | PARKERSBURG
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State | WV
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Zip | 26101-6423
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Country | US
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Telephone | 304-699-0354
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Fax |
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Provider Business Mailing Address
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Address Line | 86 VAUGHTS RUN WAY
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City | WASHINGTON
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State | WV
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Zip | 26181-9222
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Country | US
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Telephone | 304-210-8744
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4281
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License Number State | WV
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