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General NPI Number Information
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NPI Number | 1679975932
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Entity Type | Organization
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Legal Business Name | KYLE PEDIATRIC DENTAL
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Dates
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Enumeration Date | 09/18/2014
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Last Update Date | 09/18/2014
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Provider Practice Location Address
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Address Line | 575 E FM 150 SUITE P
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City | KYLE
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State | TX
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Zip | 78640-6200
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Country | US
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Telephone | 512-442-4338
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Fax |
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Provider Business Mailing Address
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Address Line | 2700 S 1ST ST
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City | AUSTIN
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State | TX
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Zip | 78704-5421
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Country | US
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Telephone | 512-442-4338
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARTY MONTGOMERY
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Credential | D.M.D.
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Telephone | 512-574-6923
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 24217
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License Number State | TX
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