Provider Demographics
NPI:1962544395
Name:DR. SHEILA BIRTH-ORTHODONTICS-KELLER, LLC
Entity type:Organization
Organization Name:DR. SHEILA BIRTH-ORTHODONTICS-KELLER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:D DS, MS
Authorized Official - Phone:817-348-0910
Mailing Address - Street 1:4420 HERITAGE TRACE PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-8904
Mailing Address - Country:US
Mailing Address - Phone:817-348-0910
Mailing Address - Fax:
Practice Address - Street 1:4420 HERITAGE TRACE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-8904
Practice Address - Country:US
Practice Address - Phone:817-348-0910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX141501223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172836201Medicaid