Provider Demographics
NPI:1104243898
Name:ABC123 DENTAL IN KELLER PLLC
Entity type:Organization
Organization Name:ABC123 DENTAL IN KELLER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-656-1215
Mailing Address - Street 1:460 KELLER PKWY STE E
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2370
Mailing Address - Country:US
Mailing Address - Phone:817-656-1215
Mailing Address - Fax:877-230-8349
Practice Address - Street 1:460 KELLER PKWY STE E
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2370
Practice Address - Country:US
Practice Address - Phone:817-656-1215
Practice Address - Fax:877-230-8349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty