MEDICARE: DR. KELLI L ETTELBRICK D.D.S., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	19146	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578505038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLI L ETTELBRICK D.D.S., M.S.

Provider Business Mailing Address
First Line	:	8380 WARREN PKWY
Second Line	:	SUITE 400
City	:	FRISCO
State	:	TX
Zip	:	75034-4198
Country	:	US
Telephone Number	:	214-387-0099
Fax Number	:	214-387-0104

Provider Business Practice Location Address
First Line	:	8380 WARREN PKWY
Second Line	:	SUITE 400
City	:	FRISCO
State	:	TX
Zip	:	75034-4198
Country	:	US
Telephone Number	:	214-387-0099
Fax Number	:	214-387-0104

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	07/27/2009

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