Provider Demographics
NPI:1063933950
Name:KELCH, SAMUEL JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JOHN
Last Name:KELCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 VAUGHTS RUN WAY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26181-9222
Mailing Address - Country:US
Mailing Address - Phone:304-210-8744
Mailing Address - Fax:
Practice Address - Street 1:1414 BLIZZARD DR
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-6423
Practice Address - Country:US
Practice Address - Phone:304-699-0354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV42811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice