Provider Demographics
NPI:1679975932
Name:KYLE PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:KYLE PEDIATRIC DENTAL
Other - Org Name:LONE STAR PEDIATRIC DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:512-574-6923
Mailing Address - Street 1:2700 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-5421
Mailing Address - Country:US
Mailing Address - Phone:512-442-4338
Mailing Address - Fax:
Practice Address - Street 1:575 E FM 150
Practice Address - Street 2:SUITE P
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6200
Practice Address - Country:US
Practice Address - Phone:512-442-4338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty