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General NPI Number Information
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NPI Number | 1356567333
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Entity Type | Individual
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Provider Name | LYLE DUANE KELSTROM DDS
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Gender | Male
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 02/21/2025
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Provider Practice Location Address
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Address Line | 6202 NE HIGHWAY 99 #5
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City | VANCOUVER
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State | WA
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Zip | 98665-8747
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Country | US
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Telephone | 360-693-2592
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Fax | 360-750-7939
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Provider Business Mailing Address
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Address Line | 6202 NE HIGHWAY 99 #5
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City | VANCOUVER
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State | WA
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Zip | 98665-8747
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Country | US
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Telephone | 360-693-2592
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Fax | 360-750-7939
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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 | DE00004874
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DE00004874
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License Number State | WA
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