Healthcare Provider Details

I. General information

NPI: 1609018548
Provider Name (Legal Business Name): PEDIATRIC DENTAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 03/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 E 13TH ST
TULSA OK
74120-5207
US

IV. Provider business mailing address

1421 E 13TH ST
TULSA OK
74120-5207
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-3744
  • Fax: 918-585-3774
Mailing address:
  • Phone: 918-585-3744
  • Fax: 918-585-3774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number784
License Number StateOK

VIII. Authorized Official

Name: DR. CHARLES R KEITHLINE III
Title or Position: MANAGING MEMBER
Credential: DDS
Phone: 918-585-3744