Provider Demographics
NPI:1669810685
Name:KELLER COSMETICS
Entity type:Organization
Organization Name:KELLER COSMETICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:JAYE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-431-6995
Mailing Address - Street 1:359 KELLER PKWY
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2206
Mailing Address - Country:US
Mailing Address - Phone:817-431-6995
Mailing Address - Fax:817-431-8813
Practice Address - Street 1:359 KELLER PKWY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2206
Practice Address - Country:US
Practice Address - Phone:817-431-6995
Practice Address - Fax:817-431-8813
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR MISTY J BROWN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-12
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18158261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental