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General NPI Number Information
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NPI Number | 1154638187
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Entity Type | Individual
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Provider Name | ANDREW BRANDON KELSO D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/13/2010
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Last Update Date | 05/18/2018
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Provider Practice Location Address
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Address Line | 330 E HIGHLAND DR
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City | LAKELAND
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State | FL
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Zip | 33813
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Country | US
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Telephone | 863-644-0430
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Fax |
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Provider Business Mailing Address
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Address Line | 2465 LAUREL GLEN DR
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City | LAKELAND
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State | FL
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Zip | 33803-5406
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Country | US
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Telephone | 954-579-0289
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | DN 19117
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DN19117
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License Number State | FL
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