MEDICARE: KIDS DENTISTREE OF ABBEVILLE-ODESSA PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1942637731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS DENTISTREE OF ABBEVILLE-ODESSA PLLC

Provider Business Mailing Address
First Line	:	621 E 7TH ST
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79761-4509
Country	:	US
Telephone Number	:	432-580-7220
Fax Number	:

Provider Business Practice Location Address
First Line	:	621 E 7TH ST
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79761-4509
Country	:	US
Telephone Number	:	432-580-7220
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	KATHIE ARMSTRONG
Credential	:
Telephone Number	:	502-254-8501

Provider Enumeration Date	:	10/11/2013
Last Update Date	:	10/14/2013

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