Provider Demographics
NPI:1588895692
Name:CHILDREN'S DENTISTRY OF KYLE
Entity type:Organization
Organization Name:CHILDREN'S DENTISTRY OF KYLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:WILHELM
Authorized Official - Last Name:WITTICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-565-6544
Mailing Address - Street 1:4100 EVERETT
Mailing Address - Street 2:STE. 215
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640
Mailing Address - Country:US
Mailing Address - Phone:512-565-6544
Mailing Address - Fax:
Practice Address - Street 1:4100 EVERETT
Practice Address - Street 2:STE. 215
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640
Practice Address - Country:US
Practice Address - Phone:512-565-6544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226161223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty