=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720546401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLER DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1431 KELLER PKWY STE 300
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-3860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-752-9828
-----------------------------------------------------
Fax | 817-752-9829
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1431 KELLER PKWY STE 300
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-3860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-752-9828
-----------------------------------------------------
Fax | 817-752-9829
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ALLEN CHARLES
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 817-752-9828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------