=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043471311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLER PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2008
-----------------------------------------------------
Last Update Date | 06/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1858 KELLER PKWY SUITE 100
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-3757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-431-6008
-----------------------------------------------------
Fax | 817-337-0098
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1858 KELLER PKWY SUITE 100
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-3757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-431-6008
-----------------------------------------------------
Fax | 817-337-0098
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. DANIEL E DONOHUE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 817-431-6008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 14921
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------