Provider Demographics
NPI:1609018548
Name:PEDIATRIC DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:KEITHLINE
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-585-3744
Mailing Address - Street 1:1421 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-5207
Mailing Address - Country:US
Mailing Address - Phone:918-585-3744
Mailing Address - Fax:918-585-3774
Practice Address - Street 1:1421 E 13TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5207
Practice Address - Country:US
Practice Address - Phone:918-585-3744
Practice Address - Fax:918-585-3774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100635530CMedicaid