Basic Information
| Provider Information | |||||||||
| NPI: | 1609018548 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC DENTAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1421 E 13TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741205207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185853744 | ||||||||
| FaxNumber: | 9185853774 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 E 13TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741205207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185853744 | ||||||||
| FaxNumber: | 9185853774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 03/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | KEITHLINE | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9185853744 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 784 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 100635530C | 05 | OK | MEDICAID |