1013080191 NPI number — DR. BRETT LEROY KEELER DDS

Table of content: DR. BRETT LEROY KEELER DDS (NPI 1013080191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013080191 NPI number — DR. BRETT LEROY KEELER DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEELER
Provider First Name:
BRETT
Provider Middle Name:
LEROY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013080191
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13012 OLD GLENN HWY
Provider Second Line Business Mailing Address:
STU. 101A
Provider Business Mailing Address City Name:
EAGLE RIVER
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99577-7568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-694-2129
Provider Business Mailing Address Fax Number:
907-694-1129

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13012 OLD GLENN HWY
Provider Second Line Business Practice Location Address:
STU. 101A
Provider Business Practice Location Address City Name:
EAGLE RIVER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99577-7568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-694-2129
Provider Business Practice Location Address Fax Number:
907-694-1129
Provider Enumeration Date:
11/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  1173 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DD1173 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".