Healthcare Provider Details

I. General information

NPI: 1750934253
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF KELLER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1627 KELLER PARKWAY SUITE 100
KELLER TX
76248
US

IV. Provider business mailing address

2101 BRADLEY DR
KELLER TX
76248-6868
US

V. Phone/Fax

Practice location:
  • Phone: 480-207-9709
  • Fax:
Mailing address:
  • Phone: 480-207-9709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JACOB JOHNSON
Title or Position: MEMBER
Credential: DDS
Phone: 480-207-9709