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General NPI Number Information
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NPI Number | 1851567499
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Entity Type | Organization
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Legal Business Name | GEORGETOWN PEDIATRIC DENTISTRY, LLC
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Dates
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Enumeration Date | 05/04/2008
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Last Update Date | 12/21/2023
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Provider Practice Location Address
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Address Line | 4507 WILLIAMS DRIVE
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City | GEORGETOWN
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State | TX
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Zip | 78633
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Country | US
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Telephone | 512-869-4100
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Fax |
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Provider Business Mailing Address
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Address Line | 4507 WILLIAMS DR
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City | GEORGETOWN
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State | TX
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Zip | 78633
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Country | US
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Telephone | 512-869-4100
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Fax |
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Authorized Official
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Title or Position | PARTNER/DENTIST
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Name | DR. KENNETH SEELY HAVARD
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Credential | D.D.S.
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Telephone | 512-818-0232
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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 | 22754
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 16755
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 23759
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License Number State | TX
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