Provider Demographics
NPI:1346597390
Name:FRISCO DENTISTRY FOR KIDS
Entity Type:Organization
Organization Name:FRISCO DENTISTRY FOR KIDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ETTELBRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:214-387-0099
Mailing Address - Street 1:8380 WARREN PKWY
Mailing Address - Street 2:STE 400
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-4198
Mailing Address - Country:US
Mailing Address - Phone:214-387-0099
Mailing Address - Fax:
Practice Address - Street 1:8380 WARREN PKWY
Practice Address - Street 2:STE 400
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-4198
Practice Address - Country:US
Practice Address - Phone:214-387-0099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578505038OtherNPI - INDIVIDUAL
1639364797OtherNPI - INDIVIDUAL