Provider Demographics
NPI:1851567499
Name:GEORGETOWN PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:GEORGETOWN PEDIATRIC DENTISTRY, LLC
Other - Org Name:COVE PEDIATRIC DENTISTRY & ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:SEELY
Authorized Official - Last Name:HAVARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-818-0232
Mailing Address - Street 1:4507 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633
Mailing Address - Country:US
Mailing Address - Phone:512-869-4100
Mailing Address - Fax:
Practice Address - Street 1:4507 WILLIAMS DRIVE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633
Practice Address - Country:US
Practice Address - Phone:512-869-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-04
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX227541223P0221X
TX237591223P0221X
TX167551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty