Provider Demographics
NPI:1891931028
Name:R. PAUL KELSON DDS MS ORTHODONTICS PA
Entity type:Organization
Organization Name:R. PAUL KELSON DDS MS ORTHODONTICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:KELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-375-3397
Mailing Address - Street 1:10497 GARVERDALE COURT
Mailing Address - Street 2:#103
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-378-1300
Mailing Address - Fax:208-375-2795
Practice Address - Street 1:10497 GARVERDALE COURT
Practice Address - Street 2:#103
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-378-1300
Practice Address - Fax:208-375-3397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID015611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty