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General NPI Number Information
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NPI Number | 1396221354
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Entity Type | Individual
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Provider Name | LARA KELLOGG DDS
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Gender | Female
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Dates
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Enumeration Date | 07/12/2018
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Last Update Date | 01/27/2021
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Provider Practice Location Address
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Address Line | 3302 GASTON AVE
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City | DALLAS
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State | TX
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Zip | 75246-2013
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Country | US
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Telephone | 832-492-6567
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Fax |
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Provider Business Mailing Address
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Address Line | 545 SEQUOIA ST
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City | ALLEN
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State | TX
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Zip | 75002-3363
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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 |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 34216
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License Number State | TX
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