Provider Demographics
NPI:1972956647
Name:OKADA, KELBY M (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELBY
Middle Name:M
Last Name:OKADA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 E US HIGHWAY 377
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-7418
Mailing Address - Country:US
Mailing Address - Phone:817-776-8073
Mailing Address - Fax:
Practice Address - Street 1:3412 E US HIGHWAY 377
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049
Practice Address - Country:US
Practice Address - Phone:817-776-8073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040979122300000X
TX333681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist