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General NPI Number Information
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NPI Number | 1205392263
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Entity Type | Organization
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Legal Business Name | BRACES ON THE BRAZOS PLLC
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Dates
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Enumeration Date | 02/14/2019
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Last Update Date | 03/02/2023
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Provider Practice Location Address
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Address Line | 1116 N MEADOWS DR
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City | GRANBURY
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State | TX
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Zip | 76048-1717
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Country | US
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Telephone | 817-573-4746
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Fax |
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Provider Business Mailing Address
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Address Line | 1116 N MEADOWS DR
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City | GRANBURY
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State | TX
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Zip | 76048-1717
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Country | US
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Telephone | 318-455-1121
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. KEITH LEE CLARK
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Credential | DDS
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Telephone | 318-455-1121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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