Provider Demographics
NPI:1922463850
Name:DR K'S PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:DR K'S PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLEHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-242-3439
Mailing Address - Street 1:1050 S COBB ST
Mailing Address - Street 2:UNIT A
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6916
Mailing Address - Country:US
Mailing Address - Phone:209-602-0686
Mailing Address - Fax:
Practice Address - Street 1:125 W EVERGREEN AVE
Practice Address - Street 2:#204
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6950
Practice Address - Country:US
Practice Address - Phone:209-242-3439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1578122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty