Organization
PEDIATRIC DENTAL GROUP, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CHARLES R KEITHLINE III DDS (MANAGING MEMBER)
(918) 585-3744
Entity
Organization
Contact information
Practice address
1421 E 13TH ST, TULSA, OK 74120-5207
(918) 585-3744
(918) 585-3774
Mailing address
1421 E 13TH ST, TULSA, OK 74120-5207
(918) 585-3744
(918) 585-3774
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
784
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100635530C
—
OK
Enumeration date
03/24/2009
Last updated
03/24/2009
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