Healthcare Provider Details

I. General information

NPI: 1194929802
Provider Name (Legal Business Name): GARLAND DUDLEY MCKELVAIN D.D.S.,MSD,INC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4224 LITTLE RD
ARLINGTON TX
76016-5601
US

IV. Provider business mailing address

4224 LITTLE RD
ARLINGTON TX
76016-5601
US

V. Phone/Fax

Practice location:
  • Phone: 817-572-4949
  • Fax: 817-478-7750
Mailing address:
  • Phone: 817-572-4949
  • Fax: 817-478-7750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11331
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: