Provider Demographics
NPI:1427099167
Name:SCHULTZ, KEVIN KELSO (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:KELSO
Last Name:SCHULTZ
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 1:10 HEARTLAND DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7741
Mailing Address - Country:US
Mailing Address - Phone:309-663-1721
Mailing Address - Fax:
Practice Address - Street 1:10 HEARTLAND DR
Practice Address - Street 2:SUITE C
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7741
Practice Address - Country:US
Practice Address - Phone:309-663-1721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0186561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice