Provider Demographics
NPI:1578505038
Name:ETTELBRICK, KELLI L (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:L
Last Name:ETTELBRICK
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8380 WARREN PKWY
Mailing Address - Street 2:SUITE 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:214-387-0104
Practice Address - Street 1:8380 WARREN PKWY
Practice Address - Street 2:SUITE 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:214-387-0104
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX191461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX090844401Medicaid