Provider Demographics
NPI:1265734594
Name:CHILDREN'S DENTISTRY OF KYLE
Entity type:Organization
Organization Name:CHILDREN'S DENTISTRY OF KYLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WITTICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-268-4400
Mailing Address - Street 1:1110 N SARAH DEWITT DR
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-3311
Mailing Address - Country:US
Mailing Address - Phone:512-268-4400
Mailing Address - Fax:512-268-4402
Practice Address - Street 1:1110 N SARAH DEWITT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3311
Practice Address - Country:US
Practice Address - Phone:512-268-4400
Practice Address - Fax:512-268-4402
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S DENTISTRY OF KYLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226161223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty