Provider Demographics
NPI:1154504918
Name:SOUTH PLAINS PEDIATRIC DENTAL GROUP
Entity Type:Organization
Organization Name:SOUTH PLAINS PEDIATRIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIETMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:806-795-9503
Mailing Address - Street 1:5102 SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-4036
Mailing Address - Country:US
Mailing Address - Phone:806-795-9503
Mailing Address - Fax:
Practice Address - Street 1:5102 SALEM AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-4036
Practice Address - Country:US
Practice Address - Phone:806-795-9503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH PLAINS PEDIATRIC DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX192641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty