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General NPI Number Information
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NPI Number | 1104478635
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Entity Type | Organization
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Legal Business Name | KELLER SMILES LLC
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Dates
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Enumeration Date | 07/15/2019
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Last Update Date | 07/15/2019
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Provider Practice Location Address
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Address Line | 1540 KELLER PKWY STE 140
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City | KELLER
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State | TX
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Zip | 76248-3685
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Country | US
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Telephone | 682-593-0993
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Fax | 682-593-0995
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Provider Business Mailing Address
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Address Line | PO BOX 4400
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City | SALEM
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State | OR
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Zip | 97302-8400
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MR. JESUS ALVARADO
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Credential |
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Telephone | 682-593-0993
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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