| Pediatric Dental Group, Llc | |
|
1421 E 13th St Tulsa OK 74120-5207 | |
| (918) 585-3744 | |
| (918) 585-3774 |
| Full Name | Pediatric Dental Group, Llc |
|---|---|
| Speciality | Dentist - Pediatric Dentistry |
| Location | 1421 E 13th St, Tulsa, Oklahoma |
| Authorized Official Name and Position | Charles R Keithline (MANAGING MEMBER) |
| Authorized Official Contact | 9185853744 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Pediatric Dental Group, Llc 1421 E 13th St Tulsa OK 74120-5207 Ph: (918) 585-3744 | Pediatric Dental Group, Llc 1421 E 13th St Tulsa OK 74120-5207 Ph: (918) 585-3744 |
| NPI Number | 1609018548 |
|---|---|
| Provider Enumeration Date | 03/24/2009 |
| Last Update Date | 03/24/2009 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1609018548 | NPI | - | NPPES |
| 100635530C | Medicaid | OK |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0221X | Dentist - Pediatric Dentistry | 784 (Oklahoma) | Primary |
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