Lyle Duane Kelstrom, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DE00004874 Issued in WA

Practice address

6202 NE Highway 99
#5
Vancouver, WA 98665-8747

Phone

(360) 693-2592

Fax

(360) 750-7939

NPI assigned

Apr 18, 2007

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective May 23, 2016 through May 23, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Interoperability endpoints

• Direct secure messaging: lkelstrom806530@direct.multicare.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Erik Jenson DMD PLLC

  • General Practice Dentistry
  • Vancouver, WA
  • NPI 1023840188
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176854400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1740096000000",
    "number": "1356567333",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6202 NE HIGHWAY 99",
            "address_2": "#5",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986658747",
            "telephone_number": "360-693-2592",
            "fax_number": "360-750-7939"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6202 NE HIGHWAY 99",
            "address_2": "#5",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986658747",
            "telephone_number": "360-693-2592",
            "fax_number": "360-750-7939"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "118 S Parkway Ave",
            "address_purpose": "LOCATION",
            "city": "Battle Ground",
            "state": "WA",
            "postal_code": "986049215",
            "country_code": "US",
            "telephone_number": "360-342-8050",
            "fax_number": "360-342-8045",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KELSTROM",
        "first_name": "LYLE",
        "middle_name": "DUANE",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-04-18",
        "last_updated": "2025-02-21",
        "certification_date": "2025-02-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "WA",
            "license": "DE00004874",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "WA",
            "license": "DE00004874",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Thomas John Kelly, DC, DIBCN
• Valerie Carla Kelly, LMP
• Virginia Sohn Kelly, M.D.
• Susan Louise Kelsay, LMFTA
• Brad Kelso, DC
• Samantha Kemp, APSW
• Brian Kempers, M.D.
• Lucyann Kendall, CDPT
• Nova Kendall
• Rebecca Ann Kendrick, OTR

• General Practice Dentistry in Vancouver, WA
• Providers in Vancouver, WA by specialty
• General Practice Dentistry in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.