=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124396312
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUBBOCK KIDS DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2011
-----------------------------------------------------
Last Update Date | 12/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1504 BUDDY HOLLY AVE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79401-5131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-749-5437
-----------------------------------------------------
Fax | 806-744-7241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1504 BUDDY HOLLY AVE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79401-5131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-749-5437
-----------------------------------------------------
Fax | 806-744-7241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. KAY KENNEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-438-4329
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------