Provider Demographics
NPI:1164930079
Name:KELLER PARKWAY DENTAL PA
Entity Type:Organization
Organization Name:KELLER PARKWAY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAIVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AFKAMI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-431-6995
Mailing Address - Street 1:1801 PRECINCT LINE RD
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3170
Mailing Address - Country:US
Mailing Address - Phone:817-431-6995
Mailing Address - Fax:
Practice Address - Street 1:359 KELLER PKWY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2206
Practice Address - Country:US
Practice Address - Phone:817-431-6995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty