1851313746 NPI number — KIM D. KEISNER, D.D.S., P.A.

Table of content: (NPI 1851313746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851313746 NPI number — KIM D. KEISNER, D.D.S., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIM D. KEISNER, D.D.S., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1851313746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1493 FOREST HILLS BLVD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
BELLA VISTA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72715-5068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-855-3313
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1493 FOREST HILLS BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BELLA VISTA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72715-5068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-855-3313
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KEISNER
Authorized Official First Name:
KIM
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
479-855-3313

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  2511 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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