=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922463850
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR K'S PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2015
-----------------------------------------------------
Last Update Date | 12/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 W EVERGREEN AVE #204
-----------------------------------------------------
City | PALMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99645-6950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-242-3439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1050 S COBB ST UNIT A
-----------------------------------------------------
City | PALMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99645-6916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-602-0686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRIAN A KELLEHER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 209-242-3439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1578
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------