Provider Demographics
NPI:1093068744
Name:KLT DENTISTRY PLLC
Entity Type:Organization
Organization Name:KLT DENTISTRY PLLC
Other - Org Name:KACI L. TIBBETTS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KACI
Authorized Official - Middle Name:
Authorized Official - Last Name:TIBBETTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-496-5422
Mailing Address - Street 1:3223 THOUSAND OAKS DR
Mailing Address - Street 2:STE #102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247
Mailing Address - Country:US
Mailing Address - Phone:210-496-5422
Mailing Address - Fax:210-490-2388
Practice Address - Street 1:3223 THOUSAND OAKS DR
Practice Address - Street 2:STE #102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247
Practice Address - Country:US
Practice Address - Phone:210-496-5422
Practice Address - Fax:210-490-2388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12844122300000X
TX26455122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty